Detail of Rajiv Gandhi Jeevandayee Arogya Yojana Maharashtra

Rs.
3000/-
GOVERNMENT OF MAHARASHTRA
Rajiv Gandhi Jeevandayee Arogya Yojana Society (Proposed) (Procurement Cell)
Arogya Bhavan 1st Floor, St.George's Hospital Compound, Near C.S.T.Station,Mumbai-400 001. Maharashtra State Website : http://maha-arogya.gov.in & www.maharashtra.gov.in Email: procurementcell@gmail.com Phone : 022-22631831/22651026,
Fax : 022-22625799 REQUEST FOR PROPOSAL (R F P)
Proposals are invited from Gene ral Insurance Companies (Licensed and Registered with IRDA) dealing with Health Insurance for implementation of Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) in Maharashtra. Technical and Financial Proposal documents can be downloaded from website http://mahaarogya.gov.in or www.maharashtra.gov.in or can also be obtained in person from below mentioned address on any working day during 2nd June 2011 to 29th June 2011 during office hours. Not Transferable RFP No. 1/DHS/PC/Rajiv Gandhi Jeevandayee Arogya Yojana/RFP/2011-12
R F P SCHEDULE
1. Date of commencement of sale of RFP
2. Pre Proposal Conference 3. Last date for availability of Proposal documents 4. Last date for submission of Proposal documents 5. Opening of technical Proposals
:
: : : :
02.06.11
17.06.11 (at 15.00 hrs.) 29.06.11 (up to 17.00 hrs.) 30.06.11 (up to 13.00 hrs.) 30.06.11 (at 14.00 hrs.).
Complete RFP documents should be submitted at the address mentioned below not later than 13.00 hrs. on 30th June 2011. Proposals received later than the prescribed deadline date and time will not be accepted for opening & evaluation.
Address for communication: Office of the Dr. G. S. Chindhe, Joint Director of Health Services (Procurement Cell) 1st Floor, Arogya Bhavan St. Georges Hospital Compound, Mumbai 400 001 Phone NO : 022-22631831 / 22651026 Telefax : 022-22625799
On behalf of Rajiv Gandhi Jeevandayee ArogyaYojana Society
All correspondence / communications about RFP, RGJA Y should be made at the above address. Issued To M/s. ___________________________________________________________________
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Si gnature & stamp of Insurance Agency
A complete set of RFP documents may be purchased by interested eligible Insurance Agency upon payment of a non refundable fee of Rs. 3000/- (Rupees Three Thousand only ) in the form of a Demand Draft issued by Nationalized/Scheduled Bank in favour of "Rajiv Gandhi Jeevandayee Arogya Yojana Society , Mumbai" payable at Mumbai during office hours from 10.00 hours to 17.00 hours on all working days on or before date & time of closing of sale of RFP document. In case of RFP which is downloaded from website, the bidder should specifically super scribe "Down loaded from the website" on the top left corner of the envelope. However RFP cost of Rs.3,000.00 in the form of Demand draft will have to be submitted along with the RFP document. The proposal shall be rejected summarily upon failure to follow procedure prescribed in the RFP document. The conditional proposal is liable to be rejected.
The Joint Director of Health Services (Procurement Cell), Mumbai reserves the right to amend /or to cancel R F P without giving any reason to.
Joint Director of Health Services (Procurement Cell) Mumbai

On behalf of Rajiv Gandhi Jeevandayee ArogyaYojana Society
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REQUEST FOR PROPOSAL (RFP) DOCUMENT (DRAFT) Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) for BPL / APL population in Maharashtra (Phase I: 8 districts of state of Maharashtra) Government of Maharashtra has decided to revamp the existing Jeevandayee Yojana by making it more comprehensive and inclusive. In pursuance with this, State is launching Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) in a phased manner in order to improve access of Below Poverty Line (yellow card holders) and Above Poverty Line (APL-orange card holders) families to quality medical care for identified specialty services requiring hospitalization for surgeries and therapies or consultations through an identified network of health care providers. The insurance policy/coverage under the RGJAY for the eligible beneficiary families in 8 districts of Phase I will be in force for an initial period of one year from the date of commencement of the policy (From 02.10.2011 Phase-I) . The RGJAY Phase-I will cover 30 specialized service categories having 972 procedures and 121 follow up procedures. While implementing the scheme in these 8 Districts the RGJAYS invites a single Proposal being implemented through the interested Insurance Companies. The scheme has following important features as detailed in the scheme. The Proposal Document consists of the following Parts . Part-I :- Details of the Sche me Part-II :- Submission of Technical and Financial Proposals Part- III :- Process assignment and General Guidelines Section A- Submission of Proposals Section B Technical Information Section C Financial Proposal Part IV :- MOU (Memorandum of Understanding ) Provisional Appendix 1: General Guidelines on the Packages. Appendix 1a: Detailed list of specified surgeries and therapies Appendix 1b: Follow up package Appendix 2: Working Pattern Appendix 3: Aarogyamitras and their role Appendix 4: Procedure of enrolment of network hospitals Appendix 5: Activity Chart for Insurance Company Appendix 6: Health camp policy Appendix 7: MOU (provisional) between insurer and network hospital Rajiv Gandhi Jeevandayee Arogya Yojana Society invites sealed competitive proposals from IRDA (Insurance Regulatory Development Authority) registered General Insurance Companies dealing with Health Insurance and having requisite experience as detailed in Request for Proposal (RFP). Only the financial proposals of those companies who qualify in the technical proposal scrutiny will be opened. The companies which are in agreement with the scheme and clauses in MoU (provisional), which is an integral part of the scheme, only need to participate in the Selection and any disagreement in this regard may invite disqualification/rejection of Proposal at technical level. Hence all the companies are requested to go through the Scheme and MoU carefully and submit their proposal.
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TABLE OF CONTENTS
SR. NO. PART I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 PART II 1 2 3 PART III 1 2 3
DETAILS SECTION-A: DETAILS OF THE SCHEME NAME OF THE SCHEME OBJECTIVES BENEFICIARY FAMILIES HEALTH CARD FAMILY IDENTIFICATION PRE EXISTING DISEASES SUM INSURED ON FLOATER BASIS PAYMENT OF PREMIUM PERIOD OF INSURANCE & PERIOD OF AGREEMENT PACKAGE CASHLESS TRANSACTION ONLINE CLAIM SETTLEMENT REFUND PROCEDURES FOR ENROLLMWNT OF HOSPITALS MOU BETWEEN NETWORK HOSPITAL AND RGJAY SOCIETY STANDARDIZATION OF FORMATS IMPLEMENTATION PROCEDURE AROGYAMITRA WEB PORTAL ONLINE MIS AND 24 HOUR E-PREAUTHORIZATION MEDICAL AUDITORS PUBLICITY IN HOUSE SYSTEM PROJECT OFFFICE AND STATE LEVEL COORDINATION CAPACITY BUILDING RUN OFF PERIOD RAJIV GANDHI JEEVANDAI MANUAL PREPROPOSAL MEETING PROPSAL VALIDITY PERIOD FORMATION OF CONSORTIUM SUBMISSION OF TECHNICAL AND FINANCIAL PROPOSALS SUBMISSION OF PROPOSALS SIGNATURE ON EACH PAGE OF DOCUMENT DEADLINE FOR SUBMISSION PROPOSALS / PROPOSALS PROCESS: ASSIGNMENT AND GENERAL GUIDELINES PROCEDURES FOR EVALUATION OF PROPOSALS AWARD OF CONTRACT RIGHT TO NEGOTIATE AT THE TIME OF AWARD
PAGE 8 8 8 9 9 9 9 10 10 10 10 12 12 12 13 13 13 14 14 15 16 17 17 17 17 17 18 18 19 19 19 19 20 20 20 20 22 22 22 22
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SR. NO. 4 5 6 7
1 2
DETAILS RGJAY SOCIETY / GOMS RIGHT TO ACCEPT OR REJECT ANY OR ALL PROPOSALS NOTIFICATION OF AWARD AND SIGNING OF MOU CONFIEDENTIALITY CANAVASSING, FRAUD AND CORRUPT PRACTICES SECTION A: SUBMISSION OF PROPOSALS GENERAL INFORMATION DECLARATION BY THE INSURANCE AGENCY SECTION B : TECHNICAL INFORMATION A. QUALIFYING CRITERIA B. OTHERS ANNEXURES Please submit the following: IRDA license Insurance company should have an experience in conceptualizing, designing and implementing large healthcare schemes and have at least three years experience Declaration from the insurer that the Insurance Agency has not been black listed/debarred An undertaking as per format expressing their explicit agreement to adhere with the details of the scheme An undertaking as per format confirming that they have submitted their Proposal as a single entity only and have not form a Consortium for the scheme. Tailor made policy of the desired Health Insurance Scheme in conformity to the benefits. The details of office infrastructure in the state and in the concerned districts. Activity Chart Plan for Health Camps. Empanelled health facilities with Insurer Any Other information, if any. SECTION C FINANCIAL PROPOSAL MOU (MEMORANDUM OF UNDERSTANDING) DEFINITION AMD INTERPRETATION BENEFICIARY FAMILIES COVERAGE SUM ASSURED PREEXISTING DISEASE PRE AND POST HOSPITALIZATION DEFINITION OF FAMILY HEALTH CARDS
PAGE 22 22 23 23 24 24 24 25 25 25
Annexure-1 Annexure-2
28 29
Annexure-3 Annexure-4 Annexure-5
30 32 33 34 35 36 37 38 39 40 41 41 43 44 45 45 45 46 46
Annexure-6 Annexure-7 Annexure-8 Annexure-9 Annexure -10 Annexure -11
PART IV 1 2 3 4 5 6 7 8
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SR. NO. 9 10 11 12 13 14
DETAILS WEB PORTAL PAYMENT OF INSURANCE PREMIUM PERIOD OF INSURANCE & PERIOD OF AGREEMENT ADJUSTMENT/ REFUND OF PREMIUM PROCEDURE FOR ENROLLMENT OF HOSPITALS MOU WITH NETWORK HOSPITAL AND DISCIPLINARY ACTIONS AGAINST THE HOSPITALS CASHLESS SERVICE PACKAGES IMPLEMENTATION PROCEDURE HEALTH CAMPS DISTRICT LEVEL CO-ORDINATION IN-HOUSE SYSTEM PROJECT OFFICE AND STATE LEVEL COORDINATION AAROGYAMITRAS WEB PORTAL ONLINE MIS AND PREAUTHORISATION MEDICAL AUDITORS PUBLICITY SERVICING OF OTHER SCHEMES ACTIVITY CHART ASSISTANCE FROM THE GOVERNMENT CLAIMS PROCEDURE RESPONSE TIME INSURER REPRESENTATIONS, WARRANTIES AND RESPONSIBILITIES JURISDICTION NON PERFORMANCE INFORMATION FLOW RENEWAL THE PRECEDENCE OF MOU MODIFICATION OF MOU MONITORING MECHANISM GRIEVANCE MECHANISM TERMS & TERMINATION FORCE MAJEURE ASSIGNMENT ENTIRE AGREEMENT RELATIONSHIP SEVERABILITY NOTICES GOVERNING LAW DISPUTE RESOLUTION
APPENDICES
PAGE 46 47 47 49 49 49 50 50 50 51 52 52 52 54 55 56 56 56 57 57 57 57 59 59 60 60 60 60 60 61 61 61 62 63 63 63 63 63 63 64 64
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49
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SR. NO.
APPENDIX I APPENDIX-Ia APPENDIX-Ib APPENDIX- II APPENDIX -III APPENDIX -IV APPENDIX V APPENDIX- VI APPENDIX- VII
DETAILS GENERAL GUIDELINES ON THE PACKAGES. DETAILED LIST OF SPECIFIED SURGERIES AND THERAPIES AND PACKAGE FOLLOW UP PACKAGE WORKING PATTERN AROGYAMITRA AND THEIR ROLE PROCEDURE FOR ENROLLMENT OF NETWORK HOSPITALS ACTIVITY CHART FOR INSURANCE COMPANY HEALTH CAMP POLICY MOU (PROVISIONAL) BETWEEN INSURER AND NETWORK HOSPITAL
PAGE 65 67 143 147 148 151 154 156 159
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PART - I Section A: Scheme

Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) would be implemented throughout the state of Maharashtra in phased manner for a period of 3 years. The insurance policy/coverage under the RGJAY for the eligible beneficiary families in 8 districts of Phase I will be in force for an initial period of one year from the date of commencement of the policy ( Phase I). The extension of period of the policy will be subject to review and renewal of the policy on a yearly basis which will be based on the quality of experience and performance as well as annual IRDA renewal. Notwithstanding, anything to the contrary mentioned elsewhere in this RFP the memorandum of understanding will be co terminus with the insurance policy/coverage which is for a term of 1 year from (From 00.00 hrs. of 02.10.2011 to Midnight of 01.10.2012 for Phase-I). Based on the quality of experience and performance of the RGJAY the State Government may at its sole discretion and without any obligation extend the RGJAY to cover the whole state. 1. NAME OF THE SCHEME: Name of the scheme is Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY). 2. OBJECTIVE : To improve access of Below Poverty Line (BPL) and Above Poverty Line (APL) families (excluding White Card Holders as defined by Civil Supplies Department) to quality medical care for identified specialty services requiring hospitalization for surgeries and therapies or consultations through an identified network of health care providers. 2.a. BENEFIT: The scheme would provide 972 surgeries/therapies/procedures along with121 follow up packages in following 30 identified specialized categories: GENERAL SURGERY 1 ENT SURGERY 2 OPHTHALMOLOGY SURGERY 3 GYNAECOLOGY AND OBSTETRICS SURGERY 4 ORTHOPEDIC SURGERY AND PROCEDURES 5 SURGICAL GASTRO ENTEROLOGY 6 CARDIAC AND CARDIOTHORACIC SURGERY 7 PEDIATRIC SURGERY 8 GENITOURINARY SYSTEM 9 10 NEUROSURGERY 11 SURGICAL ONCOLOGY 12 MEDICAL ONCOLOGY 13 RADIATION ONCOLOGY 14 PLASTIC SURGERY 15 BURNS 16 POLY TRAUMA 17 PROSTHESES 18 CRITICAL CARE 19 GENERAL MEDICINE 20 INFECTIOUS DISEASES 21 PEDIATRICS MEDICAL MANAGEMENT 22 CARDIOLOGY 23 NEPHROLOGY 24 NEUROLOGY 25 PULMONOLOGY 26 DERMATOLOGY
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27 RHEUMATOLOGY 28 ENDOCRINOLOGY 29 GASTROENTEROLOGY 30 INTERVENTIONAL RADIOLOGY Detailed list of surgeries and therapies falling under above specified categories and their package rates are given at Appendix 1 a and that of follow up package are given at Appendix 1 b of Part-IV of the document. 3. BENEFICIARY FAMILIES: Families holding yellow ration card, Antyodaya Anna Yojana card (AAY), Annapurna card and orange ration card from eight districts viz. Gadchiroli, Amravati, Nanded, Solapur, Dhule, Raigad, Mumbai city and Suburban Mumbai. The families with white ration card holding would not be covered under the scheme. The beneficiary families would be identified through the Rajiv Gandhi Jeevandayee Health Card issued by the Government of Maharashtra or based on the Yellow and Orange ration card issued by Civil Supplies Department. The total number of beneficiary families in the state would be around 2,04,30,527; out of which approximately 49 Lakh families in the 8 districts are to be covered under the scheme in first phase as on the date of publishing of the Request for Proposal (RFP) document. District wise profile of the beneficiary families is given below: Districts Population *Approximate number of Phase-I Beneficiary Families 1 Gadchiroli 970294 182889 2 Amravati 2607160 559473 3 Nanded 2876259 543961 4 Solapur 3849543 830011 Dhule 1707947 397674 5 Raigad 2207929 566231 6 Mumbai City 3338031 482073 7 8 Mumbai Suburban 8640419 1340828 26197582 4903140 Total * Based on data furnished by Civil Supplies department as on 31.05.2010. The total number of beneficiary families for each District is an indicative estimate and may vary. The number of the final beneficiary families for each district will be given within one month of signing MOU. The total premium payable would be based on this final figure of eligible beneficiary families. 4. HEALTH CARDS All eligible families in these districts shall be provided with Rajiv Gandhi Jeevandayee Arogya Yojana Health Cards in due course of time. These Health Cards will be used for identification of Beneficiary families in the family under the Scheme. Family Health Cards will be prepared by using data from valid yellow or orange ration cards coupled with Aadhaar numbers issued by UID authorities. As an interim measure till the issuance of health cards, the valid Orange/Yellow Ration Card with Aadhaar number or in case Aadhaar number not available, any Photo ID card of beneficiary issued by Govt. agencies (Driving license, Election ID,) to correlate the patient name and photograph would be accepted in lieu of health card. 5. FAMILY: Family means members as listed and photographed on the Rajiv Gandhi Jeevandayee Arogya Yojana Health Cards or holding valid Orange/Yellow Ration Card. 6. IDENTIFICATION: Health card issued by Govt. of Maharashtra/Rajiv Gandhi Jeevandayee Arogya Yojana Society or valid Orange/Yellow Ration Card with Aadhaar number if Health card is not issued would act as a tool for beneficiary identification for availing the health insurance facility. The
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following actions would be undertaken by Network hospitals in case of the possible exceptional situations:
No. Exceptional Situation Requirement for benefit Aadhaar number and in case Aadhaar number not taken any Photo ID card issued by Govt. ( Driving license, election identity card with photograph) to No Health Card with beneficiary, but correlate the patient name & photograph Valid Yellow or Orange Ration Card (In instance of emergency admission, provisional with name of beneficiary is available preauthorization may be given subject to confirmation of it against submission of valid photo identity card issued by Govt. before discharge.) Children born after issue of card i.e. Photograph of child with either parent along with name and photo not available on health Health card/ valid Yellow or Orange ration card of card or on valid yellow/Orange ration parent and Birth certificate issued by authorized office. card Name is there in Yellow or Orange Not eligible for benefit package Ration Card and matches with name in (The yellow /Orange ration card is cancelled after photo identity. But the card is invalid as verification by department but still the family is it does not match with the digitized list. holding it)
7. PRE EXISTING DISEASES: All Diseases under the proposed scheme shall be covered from day one. A person suffering from disease prior to the inception of the policy shall also be covered under approved procedures for that disease. 8. SUM INSURED ON FLOATER BASIS: The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary up to Rs. 1,50,000/- per family per year in any of the Empanelled Hospital subject to Package Rates on cashless basis through Health cards or valid Orange/Yellow Ration Card. The benefit shall be available to each and every member of the family o n floater basis i.e. the total annual reimbursement of Rs. 1.5 lakh can be availed by one individual or collectively by all members of the family. In case of renal transplant surgery, the immunosuppressive therapy is required for a period of 1 year. So the upper ceiling for Renal Transplant would be Rs. 2,50,000 per operation as an exceptional package exclusively for this procedure. The cases are likely to be very few and well controlled by Human Organ Transplant Act 1994. The claims related to this have to be settled by Insurer. 9. PAYM ENT OF PREMIUM: Rajiv Gandhi Jeevandayee Arogya Yojana Society / Government of Maharashtra will pay in advance the insurance premium in installments on behalf of insured beneficiary families to the Insurance Company as mentioned in clause 10 of Memorandum of Understanding (MOU) or as decided by the Society or GoM. 10. PERIOD OF INSURANCE & PERIOD OF AGREEMENT: The insurance coverage under the scheme for the beneficiary families in 8 districts of Phase I shall be in force for an initial period of one year from the date of commencement of the policy (From 00.00 hrs. of 02.10.2011 to Midnight of 01.10.2012 for Phase-I). The period of MOU/agreement shall be for three years with effect from 02.10.2011; subject to review and renewal of policy on yearly basis based on the quality of experience and performance as well as annual IRDA renewal. Based on the quality of experience and performance of the scheme, the State Government/ Society may extend the scheme to cover the whole state. 10.a. PERFORMANCE SCURITY: 1) The successful insurer shall furnish the security deposit to the RGJAYS within 7 days from the date of communication of Award of Contract for an amount of 5% of the contract value, valid up to 90 days after the date of completion o f warranty
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Signature & stamp of Insurance Agency
obligations and enter into MOU on Rs. 100/- non-judicial stamp paper. The cost of Stamp paper should be borne by the insurer. The Security Deposit should be in the form of Bank Guarantee in favour of the Rajiv Gandhi Jeevandayee Arogya Yojana ' payable at Mumbai from any Nationalized or Scheduled bank. 2) The Security Deposit will be discharged by the Purchaser and returned to the successful Insurance Agency not later than 30 days following the date of completion of the Insurers performance obligations by the end of first quarter of execution of scheme, including the warranty obligation, under the MOU. 3) The security deposit shall be discharged (forfeited) as a compensation for any loss resulting from the failure to perform the obligations under the MOU or in the event of termination of the MOU or in any event as the Purchaser thinks fit and proper. 4) Security deposit will not carry any interest. 10. b. PERFORMANCE PARAMETERS AND PENALTY CLAUSE: The Insurer is required to perform multiple activities in performance of its obligations arising out of the insurance contract to it. Any activity not performed by the insurer within the given time line shall hamper implementation of Rajiv Gandhi Jeevandayee Health Insurance Scheme from the planned date. Such activities have been listed here under which the successful bidder is required to complete within the specified period from the date of award of the insurance contract to it failing which a penalty as specified percentage on total premium against each section pe r week/month shall have to pay to the Society for the period of delay.
Sr. No Acti vi ty Ti me frame from the date of Signing of Agreement Penalty for the del ay in executi on i n % of component charges 1% 1% 1% 2.0%
PENALTY PER WEEK A a) Identifying the Project Officer b) Setting up of Project Office with infrastructure in Municipal Corporation of Greater Bo mbay B Preparation and Cert ification of software on receiving the specification fro m Society. C Dedicated Website as per the requirement (envisaging Empanelment MIS,HR M IS, Publicity and Camp MIS, Eauthorization MIS, Claim MIS, Follow up monitoring MIS, Field operations Support service MIS, Grievance MIS, Medical Audit MIS , Key performance Indicators, Operation maintenance MIS) D Establishment of 24 Hrs Call Center and Establish ment of other infrastructure in each covered District E Establishment of sufficient in frastructure in each covered District. Installation of kiosk, co mputer and accessories etc. F G
7 days 30 Days 3 month 3 months
3 month 3 month
1% 1% 0.5% 0.5%
To identify the Hospital Network Providers and networking 3 months with them. To arrange cashless treatment of the insured in the empanelled 3 months hospitals under the scheme and facilitation of proper networking for quick and error-free processing of preauthorizations. To provide adequate manpower, so as to ensure free flo w of 3 months daily MIS and ensure that progress of scheme is reported to Society in the desired format on a real-time basis. Preparation of various formats used for cashless transactions, 1 months discharge summary, b illing pattern and other reports in consultation with the Govern ment. PENALTY PER MONTH Processing of claims related to the scheme. Pre-authorization of System to be ready in requests and approval of preauthorization if all the conditions are 3 months (Continuing
0.5%
0.5%
1%
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Sr. No
Acti vi ty
Ti me frame from the date of Signing of Agreement
Penalty for the del ay in executi on i n % of component charges
fulfilled, within 12 hours of receiving the preauthorization request from the network provider if failure % is more than 5%) Scrutinize the b ills fro m net wo rk hosp itals an d give approval for the sanction of the bill and forward payment within 7 working days on receipt of complete claim document from the Network Hospitals. (Failure % is more than 5% ) Medical Auditing (by minimu m qualification M BBS) for conducting 20% per month concurrent audits of services and quality of service provided to the beneficiary families delivered by Network Hospitals on periodic basis as well as and required. HR a. Nu mber of network hospitals and number of Aarogymithras /Medical Coordinators, Camp Coord inators posted- District wise, month wise, and aggregate b. Nu mber of Public facilit ies (CHCs/PHCs) and number of Aarogymitras posted - District wise, month wise, and aggregate Training programme for Network Hospital Providers and other stake holders ones in a month.
activity) System to be ready in 3 months & (Continuing activity) 3rd month (Continuing activity) 3rd month Onwards 1%
0.5%
0.5%
2nd month onwards (Continuing activity)
0.5%
11. PACKAGE: The insurer should ensure that the Network hospitals follow the packages worked out by Rajiv Gandhi Jeevandayee Society. The package rates will include bed charges in General ward, Nursing and boarding charges, Surgeons, Anesthetists, Medical Practitioner, Consultants fees, Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Medicines and Drugs, Cost of Prosthetic Devices, implants, X-Ray and Diagnostic Tests, food to inpatient, one time transport cost etc. In other words the package should cover the entire cost of treatment of patient from date of reporting to his discharge from hospital or 10 days after post surgery discharge including complications if any, making the transaction truly cashless to the patient. In instance of death, the carriage of dead body from network hospital to the village/township would also be part of package. 12. CASH LESS TRANSACTION: The Insurer has to ensure that adequate facilities are provided to all beneficiary families so that they do not have to pay any deposits at the commencement of the treatment or at the end of treatment to the extent the Services as covered under the Rajiv Gandhi Jeevandayee Arogya Yojana. It is envisaged that for each hospitalization the transaction shall be cashless for covered procedures. Enrolled beneficiary will go to hospital and come out without making payment to the hospital subject to procedure covered under the scheme. The same is the case for diagnostics, if, eventually the patient does not end up in undertaking the surgery or therapy. The beneficiary has right to select network hospital and services of selected network hospital should be made available (Subject to availability of beds). In instance of nonavailability of beds at network hospital, the facility of cross referral to nearest another Network hospital is to be made available. 13. ONLINE CLAIM SETTLEMENT: The Insurance Company shall settle the claims of the hospitals online within 7 working days of receipt of the Originals bills, Diagnostics reports, Case sheet, Satisfaction letter from patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to Insurer for settlement of the claim. The online progress of claim settlement will be scrutinized and reviewed by Rajiv Gandhi Jeevandayee Arogya Yojana Society.
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14. REFUND: If there is a surplus after the pure claims experience on the premium (excluding Services Tax) at end of the policy period, after providing 20% of the premium paid towards the Companys administrative cost, of the balance 80% after providing for claims payment and outstanding claims, 90% of the left over surplus will be refunded to the Government/ Rajiv Gandhi Jeevandayee Arogya Yojana Society within 30 days after the expiry of the Run-off period. (Refer Para No. 27 related to run off period). 15. PROCEDURE FOR ENROLLMENT OF HOSPITALS: The Public and Private Hospitals will be jointly empanelled within the State of Maharashtra by Rajiv Gandhi Jeevandayee Arogya Yojana Society and Insurance Company following the empanelment procedure laid down by Rajiv Gandhi Jeevandayee Arogya Yojana Society. The hospitals having minimum of 50 inpatient hospital beds with adequate facilities and offering the services as stipulated below shall be empanelled after being scrutinized and recommended by the Empanelment and Disciplinary Committee. Empanelment and Disciplinary Committee will constitute a subcommittee of four doctors for this purpose. Two doctors will be nominated by Insurance Company and two by Rajiv Gandhi Jeevandayee Arogya Society. The purpose of this empanelment is to ensure capability of the hospital to provide some of the identified 30 specialized categories and seek agreement to the equal or lower price for these 972 procedures and 121 follow up procedures and take an opportunity to assess the current quality of care therein. It would be the responsibility of the Insurer for enrollment of Network Hospitals in the State of Maharashtra to give adequate facilities for the treatment of the patients when they present themselves. The number of empanelled hospitals and number of procedures in each hospital to be permitted will be based on the need and at discretion of the society in the interest of beneficiary. Network hospitals are supposed to extend medical aid to the beneficiary under the scheme. Procedure for enrollment of Hospitals is placed as Appendix- IV of Part IV. Preference for empanelment could be given to the hospitals accredited under National Board of Accreditation for Hospitals. It is also desired to accredit ate the empaneled hospital under National Board of Accreditation for Hospitals in order to ensure quality of care. 16. MOU WITH NETWORK HOSPITAL AND RGJAY SOCIETY. A) (i) MOU with Network Hospital: The Insurer shall sign MOU with all the network hospitals to be empanelled under the scheme. Separate MOUs with relevant provisions have to be entered into for Multispeciality, Cancer Treatment etc. This MOU is subject to the approval of the Rajiv Gandhi Jeevandayee Arogya Yojana Society. The number of empanelled hospitals and number of procedures in each hospital to be permitted will be based on the need and at discretion of the society in the interest of beneficiary. Network hospitals are supposed to extend medical aid to the beneficiary under the scheme. A provision will be made in MOU regarding noncompliance / default clause. Such matter shall be looked in to by the Empanelment and Disciplinary Committee, the decision of which will be binding to all concerned. (ii) Disciplinary actions against the hospitals: On recommendation by the Empanelment and Disciplinary Committee the Insurer shall take various disciplinary actions against Network Hospital including De- listing from the empanelment if it is found that guidelines of the Scheme are not followed by it and services offered are not satisfactory as per laid down standards. Hospital may also be delisted or deempanelled if infrastructure in the hospital is found below the standards laid down by the society any time during the policy period. In case of any delisting of empanelled hospitals, the insurer shall find alternative immediately. B) (i) MoU with Rajiv Gandhi Jeevandayee Aarogya Yojana society
[
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The Insurer shall enter into the MOU with GOM / Rajiv Gandhi Jeevandayee Arogya Yojana Society given in Part IV (Provisional), which is an integral part of the scheme within 24 hours of award of contract. (ii) Nonperformance by insure r In the event of non-performance by the Insurer as per the guidelines ( refer Clause 10.a) of the scheme, the insurer shall abide by the clause 11, 11.a and 17 as per MOU given in Part IV of the document. 17. STANDARDIZATION OF FORMATS: The Insurance Company shall standardize various formats used for cashless transactions, discharges summary, billing pattern and other reports in consultations with Rajiv Gandhi Jeevandayee Society. 18. IMPLEMENTATION PROCEDURE: The Entire scheme is to be implemented as cashless hospitalization arranged by the Insurance Company. The following represents the process flow of treatment to the beneficiary. A) Process Flow of the Beneficiary Treatment in the Network Hospital Step 1 Beneficiary families shall approach nearby PHC/Rural, Sub district, General, Women/District Hospital/Network Hospital. Aarogyamitras placed in the above hospitals s hall facilitate the beneficiary. If beneficiary visits Government Health Facility other than the Network Hospital, he/she will be given a referral card to the Network Hospital with preliminary diagnosis by the doctors. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the Villages and can get that referral card based on the diagnosis. The information on the outpatient and referred cases in the PHC/Rural, Sub district, General, Women/DH and the camps will be collected from all Aarogyamitras/Hospitals on regular basis and captured in the dedicated database through a well-established call center. Step 2 The Aarogyamitras at the Network Hospital examine the referral card and health card or Yellow/Orange Ration Card, register the patients and facilitate the beneficiary to undergo specialist consultation, preliminary diagnosis, basic tests and admission process. The information like admission notes, test done will be captured in the ded icated database by the Medical Coordinator of the Network Hospital as per the requirement of the Rajiv Gandhi Jeevandayee Arogya Yojana Society. Step 3 The Network Hospital, based on the diagnosis, admits the patient and sends Epreauthorization request to the insurer, same can be reviewed by Rajiv Gandhi Jeevandayee Arogya Yojana Society. Step 4 Recognized Medical Specialists of the Insurer and Rajiv Gandhi Jeevandayee Arogya Yojana Society examine the preauthorization request and approve preauthorization, if, all the conditions are satisfied. This will be done within 12 working hours and immediately in case of emergency wherein e-preauthorization is marked as EM. Step 5 The Network Hospital extends cashless treatment and surgery to the beneficiary. The Postoperative notes of the Network Hospitals will be updated on the website by the medical coordinator of the Network Hospital. Step 6 Network Hospital after performing the covered surgery/ therapy/ procedure forwards the Originals bills, Diagnostics reports, Case sheet, Satisfaction letter from patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to Insurer for settlement of the claim. The Discharge S ummary and follow- up details will be part of the Rajiv Gandhi Jeevandayee Arogya Yojana Society portal.
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Step 7 Insurer scrutinizes the bills and gives approval for the sanction of the bill and shall make the payment within agreed period as per agreed package rates. The claim settlement module along with electronic clearance and payment gateway will be part of the workflow in Rajiv Gandhi Jeevandayee Arogya Yojana Society portal and will be operated by the Insurer. The reports will be available for scrutiny on the Rajiv Gandhi Jeevandayee Arogya Yojana Society login. Step 8 The Network Hospital will provide free follow-up consultation, diagnostics, and medicines under the scheme up to 10 days from the date of discharge. B) Health camps Health Camps are to be conducted in Taluka Head Quarters, Major Gram Panchayats and Municipalities. Minimum of one camp per week per empanelled hospital has to be held in the eight districts in the policy year. The insurer shall ensure that at least one free medical camp is conducted by each network hospital per week at the place suggested by Rajiv Gandhi Jeevandayee Arogya Yojana Society. The Rajiv Gandhi Jeevandayee Medical Camp Coordinator MCCOs of the hospital shall coordinate the entire activity. Network hospital shall carry necessary screening equipment along with specialists (as suggested by the Rajiv Gandhi Jeevandayee Arogya Yojana Society) and other Para- medical staff. The Insurer shall put in the minimum requirements as regards the health camp in the MOU with the hospitals. The empaneled hospital shall work in close liaison with district coordinator of the Insura nce Company, Civil Surgeon/District Health Officer in consultation with District Collector. Hospital shall follow the Camp policy of Rajiv Gandhi Jeevandayee Arogya Yojana Society. C) District level co-ordination: District level offices with necessary infrastructure have to be setup by the Insurance Company. The Insurer needs to have district level monitoring staff with District Coordinators, & State Coordinators of the Insurance Company. They should monitor Aarogymitras, coordinate with network hospital, district administration and peoples representatives for effective implementation of the Scheme. They should ensure that camps are held as per schedule, arrange for canvassing for the camp, mobilize patients and follow up the beneficiary families. They should work in close liaison with district administration under the supervision of District Collector. They should also ensure proper flow of MIS and report to society on day to day basis about the progress of the scheme in the district. The Insurance Company should ensure that dedicated staff is made available for the scheme. There shall be at least one doctor to be placed in each district. Further, wherever the concentration of the Network Hospitals is more additional doctors need to be placed. The Insurance Company shall follow the instructions of Rajiv Gandhi Jeevandayee Arogya Yojana Society in this regard. 19. AAROGYAMITHRAS a) Aarogyamithras in Primary Health Centers (PHC)/Rural Hospitals (RH)/Sub District Hospitals(SDH)/District Hospitals (DH)/General Hospitals (GH)/Women Hospitals(WH): The unique nature of the scheme demands the insurance company to appoint Aarogyamithras in consultation with Rajiv Gandhi Jeevandayee Arogya Society in PHCs/RH/SDH/GH/WH and district Hospitals of selected 8 Districts for propagating the scheme, mobilizing people for health camps, counseling beneficiary families facilitating the referral/treatment of these patients and follow up. For effective and instant Communication all the Aarogyamithras will have to be provided with cell phone CUG connectivity by the Insurance Company. b) Aarogyamithras in Network Hospitals: The Insurance Company also needs to appoint at least one Aarogyamithra at all network hospitals round the clock to facilitate admission, treatment and cashless transaction of patient. The Aarogyamithras should also help hospitals in pre-authorization, claim settlement and follow- up. They should also ensure proper reception and care in the hospitals and send regular MIS to call center. Insurance Company shall provide all Aarogyamithras with cell phone having CUG connectivity with SMS based
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reporting framework for effective and instant communication. The Insurance Company shall ensure that prefabricated Aarogyamithras kiosks with all additional requirements as per the design approved by the society is put up in all hospitals. The role of Aarogyamithras can be modified by Rajiv Gandhi Jeevandayee Arogya Yojana Society from time-to-time. The Insurer will provide uniform and arrange the workshops/training sessions for the Aarogyamithras as per guidelines specified by Rajiv Gandhi Jeevandayee Society. The detailed note on Aarogyamithras and their role are given at Appendix III of Part-IV of the document. 20. WEB PORTAL: All activities related to the scheme shall be done through a dedicated portal of Rajiv Gandhi Jeevandayee Society, the development and maintenance cost of which will be borne by the Insurer. The source code and system design document for the application exclusively developed by Insurer for Rajiv Gandhi Jeevandayee Arogya Yojana shall be provided in good working condition to Rajiv Gandhi Jeevandayee Arogya Yojana Society. A dedicated data center in the name of Rajiv Gandhi Jeevandayee Yojana will be maintained by the Insurer. The proprietary rights of software will be with Government of Maharashtra and the Insurance Company shall execute all the necessary documents for assignment/transfer of the software to the Rajiv Gandhi Jeevandayee Arogya Yojana Society. Patient records will be property of Rajiv Gandhi Jeevandayee Arogya Yojana Society. Confidentiality of patient records shall be maintained by the Insurer. Insurance Company will develop the Software as per the requirement of the Scheme on the directions & guidelines as mandated by Rajiv Gandhi Jeevandayee Arogya Yojana Society. The web portal will be a repository of information and will have the following features and the respective workflows: 1. General Information on the scheme. 2. Details of patients reporting and referrals from the PHC / Rural/ S ubdistrict/Women/General/District hospitals on daily basis. 3. E-Health Camps system and daily reporting of health camps. 4. Details of patients reporting and getting referred from the health camps. 5. E-Empanelment system. 6. Emergency approval system. 7. Call centre application. 8. Patient registration by Aarogyamithra in Network Hospitals. 9. Details of in-patients and out patients in the network hospitals. 10. On-bed reporting system. 11. Costing of the Tests done in the network hospitals. 12. E-preauthorization. 13. Surgery details. 14. Discharge details. 15. Real-time reporting, active data warehousing and analysis system. 16. Claim settlement. 17. Electronic clearance of bills with payment gateway. 18. Follow- up of patient after surgery. 19. Distribution of Follow-up medicines. 20. Rajiv Gandhi Jeevandayee Messaging Services. 21. Grievance and Feedback workflow. 22. Back Tracking System. 23. E-Office management. 24. Accounting system. 25. TDS workflow. 26. Death reporting system.
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21. ONLINE MIS AND 24 HOURS E- PREAUTHORIZATION. The Insurance Company should post enough dedicated staff, so as to ensure free flow of daily MIS and ensure that progress of scheme is reported to society in the desired format on a realtime basis. The company should establish proper networking for quick and error- free processing of pre-authorizations. The pre-authorization has to be done round the clock in co-ordination with Rajiv Gandhi Jeevandayee Arogya Yojana Society i.e. by a team of doctors from the Rajiv Gandhi Jeevandayee Arogya Yojana Society and Insurance Company. The preauthorization team shall have all the specialists concerned with the procedures covered in the scheme on a permanent basis. Rajiv Gandhi Jeevandayee Arogya Yojana Society will provide necessary specialists and technical committees to evaluate special cases from time-totime. Rajiv Gandhi Jeevandayee Arogya Yojana Society will provide necessary specialists to evaluate special cases. A technical committee consisting of specialist from Government Sector nominated by Rajiv Gandhi Jeevandayee Society in the concerned field, CMO of the Insurer and the Project Manager of the Insurer will evaluate and recommend to the CEO of Rajiv Gandhi Jeevandayee Society. In instance of dispute, the final decision on preauthorization rest with the CEO of Rajiv Gandhi Jeevandayee Society. There should be inbuilt anonymity of name of network hospital and health card number in the software while giving preauthorization and claim settlement. 22. MEDICAL AUDITORS : The Insurance Company shall appoint enough number of medical auditors, who do preauthorization in consultation with Rajiv Gandhi Jeevandayee Society. The Insurer shall also recruit specialized doctors for regular inspection of hospitals, attend to complaints from beneficiary families directly or through Aarogyamithras for any deficiency in services by the hospitals and also to ensure proper care and counseling for the patient at network hospital by coordinating with Aarogyamitras and hospital authorities. 23. PUBLICITY: The Insurance Company on its part should ensure that proper publicity is given to the scheme in all possible ways. This will include publicity on electronic and print media, distribution of brochures, banners, display boards etc. in public at appropriate places in consultation with RGJAYS. The annual spending on this activity should be two percent of total premium amount received annually by the insurer. They shall also effectively use services of Aarogyamitras and district Coordinators for this purpose. 24. IN HOUSE SYSTEM: The Insurer will establish inhouse system to provide all such facilities elaborated under the scheme. The Insurer will submit detailed list of staff appointed for Rajiv Gandhi Jeevandayee Arogya Yojana with their designations, responsibilities and contact numbers before the commencement of policy to the RGJAYS. 25. PROJECT OFFICE AND STATE LEVEL COORDINATION The insurer shall nominate within 7 days of signing the MOU responsible officer/officers to properly coordinate above work and ensure proper implementation of scheme up to the satisfaction of Rajiv Gandhi Jeevandayee Society. They shall review the progress with Rajiv Gandhi Jeevandayee Arogya Yojana Society on day-to-day basis and be responsible to implement the suggestions of Rajiv Gandhi Jeevandayee Arogya Yojana Society for effectively running the scheme. The Project Office of the Insurance Company shall be separately established at a place desired by Rajiv Gandhi Jeevandayee Arogya Yojana Society and also provide adequate space for Society for better coordination. The Project office shall report to the Rajiv Gandhi Jeevandayee Arogya Yojana Society on a daily basis in the prescribed proformas. The following departments shall be established by the Insurance Company in the Project Office:
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a. 24 hour call cente r with toll free help line and online workflow. b. Field Operations Departme nt to coordinate the daily activities of field staff. c. MIS Department to collect, collate and report data on a real time basis. This department will also have a subunit with operators who collect hourly information from the Aarogyamitras, regional co-coordinators, district coordinators etc. Based on this the reverse flow of dissemination of information shall also take place. There shall be subunits for each district. The MIS department shall also follow- up the cases at all levels. The department shall also generate reports as desired by Rajiv Gandhi Jeevandayee Society. d. HR Department to manage human resources for the scheme. e. Training Departme nt for capacity building of all stakeholders (those who affect the outcome and those who are affected by outcome) and staff. f. IT Departme nt to ensure that the website with e- pre-authorization, claim settlement and real time follow-up is maintained and updated on a 24 hour basis. g. Round the clock pre-authorization Departme nt with specialist doctors for each category of diseases shall work round the clock along with Rajiv Gandhi Jeevandayee Arogya Yojana Society doctors to see that the pre-authorization is given within 12 working hours and immediately in case of emergencies. The doctors shall also undertake inspection of hospitals. h. Claims settlement Departme nt with electronic clearance facilities. i. Health Camp Department to plan intimate implement and follow-up the camps as per the directions of Rajiv Gandhi Jeevandayee Society. j. Publicity and logistics Department to undertake all the publicity and logistics activities as specified by Rajiv Gandhi Jeevandayee Society. k. Grievance Department to be manned by doctors and other staff to address the grievances as per the instructions of the Rajiv Gandhi Jeevandayee Society. l. Follow up Department to coordinate the follow-up consultations and distributions of drugs as per the instructions of Rajiv Gandhi Jeevandayee Society. m. Empanelment Departme nt to empanel the hospitals in the network as per the guidelines given by the society and monitor the compliance. n. Feedback Department to send feedback formats collect and analyze feedback of the patients as per the directions of Rajiv Gandhi Jeevandayee Society. The Department will also document each case and upload the same in the Rajiv Gandhi Jeevandayee Arogya Yojana Society portal. o. Administration Department for office management. p. Vigilance Department for keeping vigil on all services providers and staff q. Accounts Department r. Other Departments required for office work. 26. CAPACITY BUILDING I. The Insurer will arrange the workshops / training sessions for the capacity building of the society personnel, their representatives and other stakeho lders in respect of specific field of insurance at each district on the convenience of the society. Insurer will ensure that workshops and medical camps are organized in association with the network hospitals. II. The help of NGOs/SHGs will be taken by the Rajiv Gandhi Jeevandayee Help Desk/Rajiv Gandhi Jeevandayee Assistance Counters to spread awareness and guide the prospective patients to the network hospitals. The Insurer will associate in this task. 27. RUN OFF PERIOD A Run off Period of one month will be allowed after the expiry of the policy. This means that pre-authorization can be done till the end of policy period and surgeries for such pre-
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authorizations can be done up to one month after the expiry of policy period and all such claims will be honored by the Insurance Company. 28. RAJIV GANDHI JEEVANDAI MANUAL Rajiv Gandhi Jeevandayee Arogya Yojana Society will publish a detailed Manual for the Scheme titled Rajiv Gandhi Jeevandayee Arogya Yojana Manual consisting of all operational guidelines and details of the scheme. Rajiv Gandhi Jeevandayee Arogya Yojana Society may update and modify these guidelines and operational details as per the requirement of the scheme. The insurer shall follow the guidelines and instructions given in the manual while implementing the scheme. 29. PRE PROPOSAL MEETING 1. A Pre Proposal meeting of the prospective bidders will be held at 15.00 hrs. on 17.06.2011 in the Conference Hall of Arogya Bhavan, Directorate of Health Services Mumbai, to clarify any queries the Insurance Agencies may have, and for providing additional information if any. No separate intimation of the Pre Proposal meeting will be sent to the prospective Insurance Agencies, unless there is a change in the time, date or venue of the Pre Proposal meeting. 2. A copy of the proceedings of the Pre Proposal meeting will be sent to all the prospective Insurance Agencies. The decisions and clarifications denoted in the Proceedings of the Pre Proposal meeting shall be final and binding to all the Insurance Agencies & minuted decision of pre proposal meeting will be a part of RFP document. 30. PROPOSAL VALIDITY PERIOD: 1. The Proposal shall remain valid for a maximum period of six calendar months from the Date of declaration after opening financial proposal. 2. (Technical bid). A bid valid for a shorter period shall be rejected
3.. Prior to the expiration of the bid validity the Purchaser may request the Insurance Agency to extend the bid validity for the period as required by the Purchaser
31. FORMATION OF CONSORTIUM: Eligible Insurance Agencies shall submit their Proposal as a single entity only. Formation of Consortium is not allowed to Proposal. Such Proposals shall be cancelled and not evaluated.
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PART II SUBMISSION OF TECHNICAL AND FINANCIAL PROPOSALS Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra seek detailed Proposal documents from insurance companies interested in implementing Rajiv Gandhi Jeevandayee Yojana for 30 identified specialized categories envisaging 972 procedures and 121 follow up procedures in all the districts of Maharashtra for approximately 2 crore families for a period of 3 years, with a proviso that initially scheme will be launched in 8 districts of State of Maharashtra for approximately 49 lakh families for 1 year. Renewal of scheme after initial one year and also extension to other districts of the state will be subject to the review of quality of experience and also performance of the scheme. 1. SUBMISSION OF PROPOSALS: The Insurance Agency must submit the proposal as per the details me ntioned below: i. Technical proposal both hard and soft format should be sealed in a separate envelop clearly marked in BOLD SECTION A & B - TECHNICAL PROPOSAL OF RAJIV GANDHI JEEVANDAI YOJANA FOR EIGHT DISTRICTS written on the top of the envelope. Under no circumstances shall the financial quote appear anywhere in Technical Proposal and the technical Proposal shall stand rejected if quoted. ii. Financial proposal in hard format should be sealed in another envelop clearly marked in BOLD SECTION C- FINANCIAL PROPOSAL FOR RAJIV GANDHI JEEVANDAI YOJANA FOR EIGHT DISTRICTS written on the top of the envelope. iii. Both envelop should have the Insurance Agencies Name and Address clearly written at the Left Bottom Corner of the envelope. iv. Both envelops should be put in a larger cover / envelop, sealed and clearly marked in BOLD have SECTION A&B TECHNICAL PORPOSAL FOR RAJIV GANDHI JEEVANDAI YOJANA FOR EIGHT DISTRICTS SECTION C FINANCIAL PROPOSAL FOR RAJIV GANDHI JEEVANDAI YOJANA FOR EIGHT DISTRICTS Written on envelop and have the Insurance Agencies Name and Address clearly written in BOLD at the Left Bottom Corner. v. The Proposals shall be cancelled and not evaluated if the Insurance Agency fails to: a. Clearly mention Technical / Financial Proposal on the respective envelops as mentioned in clause 1.0 I to IV above under Part III. b. To seal the envelope properly with sealing tape. c. Submit both envelops i.e. financial proposal and Technical Proposal together keeping in large envelop. d. Give complete Proposals in all aspects. e. Submit Financial Proposals in the specified proforma (Section C). f. To submit soft copy of Technical Proposal in respective cover. 2. SIGNATURE ON EACH PAGE OF DOCUMENT: The competent authority of the Insurance Agency must sign and put official stamp on eac h paper of Proposal. Any document / sheet not signed may lead to rejection of Proposal. 3. DEADLINE FOR SUBMISSION of PROPOSAL / PROPOSALS: Complete Proposal documents should be received at the address mentioned below not later than 13.00 hrs. on 30 th June 2011. Proposal documents received later than the prescribed date and time will not be entertained under any circumstances. Late Proposal documents on any count shall be rejected summarily. Delay due to Post or any other reason will not be condoned.
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Complete Proposal documents should be submitted in two envelopes i.e. Technical RFP in
envelope no.1& Commercial bid in Envelope no. 2. Both bids i.e. Technical RFP & Commercial RFP should be put in one envelope indicating RFP No. Subject & Date of opening of RFP
Address : Dr. G. S. Chindhe, Joint Director, Procurement cell, Directorate of Health Services, On behalf of Rajiv Gandhi Jeevandayee Arogya Yojana Society Arogya Bhavan First Floor, Procure ment cell, St. Georges Hospital campus, Mumbai 400001Mumbai Phone: 022-22631831, 022-22651026 Fax: 022-22625799 E-mail: procurementcell@gmail.com
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PART-III PROCESS: ASSIGNMENT AND GENERAL GUIDELINES 1. PROCEDURE FOR EVALUATING PROPOSALS The Proposals received within stipulated period and collected in Proposal Box are opened in the presence of Company Representatives. First the Larger Covers are opened and then Technical and Financial Proposals will be segregated. Then the Technical Proposals will be opened in the presence of Company Representatives. Technical Committee nominated by Rajiv Gandhi Jeevandayee Arogya Society / Government of Maharashtra will evaluate the technical proposals. Once the technical Proposals have been evaluated, the successful Insurance Agencies will be informed about the date of opening of financial Proposals. Financial Proposals of only those Insurance Agencies will be opened who are declared successful in the technical Proposal Evaluation stage. Insurance company which are in full conformity with RFP requirements and conditions shall be declared as Eligible insurance company for opening Envelope no. 2 and Envelope No. 2 (Commercial bid) of such insurance company shall be opened later, on a given date and time. Financial Proposals will be opened in presence of the representatives of insurance companies that have been declared successful in the technical Proposal evaluation stage. Then Financial Proposals will be evaluated by financial committee nominated by Rajiv Gandhi Jeevandayee Arogya Society / Government of Maharashtra. The Technical and Financial proposals should be sealed by the Insurance Agency in separate covers duly super-scribed and both these sealed covers are to be put in a bigger cover which should also be sealed and duly super-scribed. The Technical Proposals will be evaluated by the Technical Proposal Evaluation Committee duly constituted by the Government of Maharashtra ( GOM ). Financial Proposals of only the technically acceptable offers shall be opened before the successful Insurance Agencies. 2. AWARD OF CONTRACT Rajiv Gandhi Jeevandayee Arogya Yojana Society / Government of Maharashtra shall award the contract to the successful Insurance Agency whose Proposal has been determined to be substantially responsive, lowest evaluated Proposal, provided further that the Insurance Agency has been determined by the Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra to be qualified to perform the contract satisfactorily. 3. RIGHT TO NEGOTIATE AT THE TIME OF AWARD Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra reserve the right to negotiate with lowest Insurance Agency after opening the Financial Proposal. 4. RAJIV GANDHI JEEVANDAI AROGYA YOJANA SOCIETY / GOVERNMENT OF MAHARASHTRAS RIGHT TO ACCEPT OR REJECT ANY OR ALL PROPOSALS : Rajiv Gandhi Jeevandayee Arogya Yojana Society / Government of Maharashtra reserves the right to accept or reject any Proposal or annul the Selection process and reject all Proposals at any time without assigning any reason prior to award of contract, without thereby incurring any liability to the affected Insurance Agency or Agencies. Rajiv Gandhi Jeevandayee Arogya Yojana Society / Government of Maharashtra is not bound to accept the lowest or any Proposal. Incomplete Proposals and financial Proposals with extra attachments are liable to be disqualified. 5. NOTIFICATION OF AWARD AND SIGNING OF MOU: The Notification of Award will be issued with the approval of the Proposal Accepting Authority. The terms of MOU are non-negotiable and the successful insurance company shall sign the MOU proposed by Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra at part IV of the document in duplicate within 24 hours of declaration of award of contract, failing which the contract may be offered to the next Insurance Agency in order of merit. Once the MOU is signed, the insurer will have no right to cancel the MOU signed between Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra and insurer.
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6. CONFIDENTIALITY: Information relating to the examination, clarification, evaluation, and comparison of proposals, and recommendations for the award of a Contract shall not be disclosed to insurers or any other persons not officially concerned with such process until the notification of Contract award is made. Any effort by the insurer to influence the Purchaser in the Purchaser's proposal evaluation, proposal comparison, or contract award decisions may result in the rejection of the Insurer's proposal. 7. CANVASSING, FRAUDULENT AND CORRUPT PRACTICES: Insurance Agencies are hereby informed that canvassing in any form for influencing the process of notification of award would result in disqualification of the Insurance Agency. Further, they shall observe the highest standard of ethics and will not indulge in any corrupt, fraudulent, coercive, undesirable or restrictive practices, as the case may be. Corrupt practice means the offering, giving, receiving or soliciting of anything of value to influence the action of the public official Fraudulent practice means a misrepresentation of facts in order to influence RFP process or an execution of a contract to the detriment of RGJAY, and includes collusive practice among Insurers/Authorized Representative (prior to or after Proposal submission) designed to establish Proposal prices at artificial non-competitive levels and to deprive RGJAY free and open competition; Collusive practice means a scheme or arrangement between two or more Insurance Agency, with or without the knowledge of the Purchaser, designed to establish RFP prices at artificial, noncompetitive level; and Coe rcive practice means harming or threatening to harm, directly or indirectly, persons or their property to influence their participation in the procurement process or effect the execution of the contract Government of Maharashtra will re ject a proposal for award if it determines that the Insurer/Insurers have engaged in corrupt or fraudulent practices Government of Maharashtra will declare a firm ineligible, either indefinitely or for a stated period of time, to be awarded a contract if it at any time determines that the Selection Insurer/Insurers has engaged in corrupt and fraudulent practices in competing for, or in executing, a contract. Amendment/Cancellation of Proposal Documents a) At any time prior to the deadline for submission of Proposals, the Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra may, for any reason modify the RFP documents, by amendment or cancel the process.
b) The amendment will be notified in writing/by e-mail/by fax or through website to all prospective Insurance Agencies who have taken the RFP documents and amendments will be binding on them. c) To give prospective Insurance Agencies reasonable time in which to take the amendment into account in preparing their RFP document, the Purchaser shall extend, at its discretion, the deadline for submission of RFP document, in which case, the Purchaser will notify all Insurance Agencies by placing it on website of the extended deadline and will be binding on them. d) Any addendum/corrigendum as well as clarification thus issued shall be a part of the RFP documents and it will be assumed that the information contained in the amendment will have been taken into account by the Insurance Agencies in its RFP.
NOTE: Oral statements made by the Insurance Agency at any time regarding quality of service or arrangements of any other matter shall not be considered.
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SECTION A GENERAL INFORMATION AND UNDERTAKING BY THE INSURANCE AGENCY IN THE PRESCRIBED PROFORMA ENCLOSED. TECHNICAL PROPOSAL GENERAL INFORMATION 1 Name of the Insurance Company 2 3 4 Address of Head Office Name and designation of the person submitting the proposals Status
Public Sector / Private Sector
DECLARATION BY THE INSURANCE AGENCY I, _________________________________ Designated as _______________ at_____________________________ of ___________________________ Insurance Company hereby declare that I have read & the contents of the RFP document , consisting of Part I to IV and having agreed to the contents here by submit the Proposal in the desired format with respective proformas duly signed by me , If our Proposal is found successful, the company is agreeable to execute the MoU as given in part II with in twenty four hours (excluding public holidays) after the award.
DATE:
AUTHORIZED SIGNATORY
Seal
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Technical Information
(A) Qualifying Criteria: a. General Insurance Company should be registered with IRDA to undertake insurance related activities. The Insurer should attach a self-attested recent copy of the license as a proof of its registration (Annexure-1 of Part III). Insurance company should have an experience in conceptualizing, designing and implementing large health insurance schemes and have at least three years experience in catering to health insurance of 10,00,000 families or more enrolled under each group health insurance policy in the year 2008-09, 2009-2010 and 2010-2011 (Annexure -2 of Part III). Health insurance policies issued for various districts within a State for specific scheme implemented by state/pan India scheme implemented by Central Govt. on all India basis will be considered as one policy during the financial year. b. Insurance Company must submit supporting attested documents of past performance along with RFP. Insurance Agency must furnish their complete business address
VAT/TAN. PAN registration documents attested copies and a Certificate from Charted Accountant showing revenue income receipts on said business during last three financial years. Insurance Company shall produce Audited Balance Sheet and Profit and Loss Accounts for last three years i.e. 2007-08, 2008-09 & 2009-10 certified by the Auditor.
SECTION B
c. Declaration from the insurer that the Insurance Agency has not been black listed/debarred by any State Government/Central Government o r its agencies or not qualified in participating the Government schemes as per IRDA guidelines. (Annexure -3 of Part III) Declaration from the insurer that the Insurer will establish inhouse system to provide all such facilities elaborated under the scheme.. (Annexure -3a of Part III) d. The Insurer has to provide an undertaking, as per format expressing their explicit agreement to adhere with the details of the scheme as mentioned in the Part I of the RFP document. (Annexure -4 of Part III) e. The Insurer has to provide an undertaking, as per format confirming that they have submitted their Proposal as a single entity only and have not form a Consortium for the scheme. (Annexure 5 of Part III) f. Tailor made policy of the desired Health Insurance Scheme in conformity to the benefits available, exclusions, conditions etc. There is no structured format for this. (Annexure 6 of Part III) B. Othe rs: (i) Office Infrastructure Company shall submit the details of office infrastructure in the state and in the concerned districts in Annexure 7. A detailed organogram with existing manpower may be attached apart from the annexure if desired. (Annexure 7 of Part III) (ii) Activity Chart The scheme covering the valid yellow and orange ration card holders needs to be launched within time frame. Hence the Insurance Company shall submit a time bound action plan, not exceeding the date of launch, in Annexure 8 to mobilize sufficient infrastructure and manpower as per the requirement. (Annexure-8 of Part III) (iii) Plan of Health Camps The Insurance Agency shall give a detailed action plan on organizing health camps as prescribed in Para 18 D of part I. There is no structured format for this. (Annexure-9 of Part III) (iv) Empanelled Health Facility with the Ins urance Agency Fresh empanelment of network hospitals has to be done for this Phase. Hence the number of specialty hospital already empanelled with the Insurance Company in other schemes in the
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State and concerned Districts. Insurer shall enumerate only those hospitals having requisite infrastructure as per the scheme. (Annexure-10 of Part III) (v) Any Other Information, if any. Any other information Insurer desires to inform, which is relevant to the scheme. There is no structured format for this. (Annexure-11 of Part III) NOTE: Insurance Agency shall give point wise reply of the RFP document for agreement / disagreement and attach the necessary annexure as mentioned above.
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Please submit the following: 1 -Qualifying Details Annexures of Crite ria: Part III a IRDA license Annexure-1 b Insurance company should have an experience in Annexure-2 conceptualizing, designing and implementing large healthcare schemes and have at least three years experience in catering to health insurance of 10,00,000 families across the country or more underwritten under each group health insurance policy in the financial year 2008-2009, 2009-2010 and 2010-2011 on State / Pan India basis. c Declaration from the insurer that the Insurance Agency has Annexure-3 not been black listed/debarred by any State Government/Central Government or its agencies or not disqualified in participating the Government schemes as per IRDA guidelines. Declaration from the insurer that the Insurer will establish Annexure-3a inhouse system to provide all such facilities elaborated under the scheme. d An undertaking as per format expressing their explicit Annexure-4 agreement to adhere with the details of the scheme as mentioned in the Part I of the RFP document. e An undertaking as per format confirming that they have Annexure-5 submitted their Proposal as a single entity only and have not form a Consortium for the scheme. f Tailor made policy of the desired Health Insurance Scheme Annexure-6 in conformity to the benefits available, exclusions, conditions etc. There is no structured format for this. 2 - Others i Company shall submit the details of office infrastructure in Annexure-7 the state and in the concerned districts. A detailed organogram with existing manpower may be attached apart from the annexure if desired. ii Activity Chart Annexure-8 iii Plan for Health Camps. There is no structured format for Annexure-9 this. iv Empanelled health facilities with Insurer Annexure-10 v Any Other information, if any. There is no structured Annexure-11 format for this.
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ANNEXURE-1 ATTACH ATTESTED COPY OF IRDA LICENSE
~ 28 ~
ANNEXURE-2 EXPERIENCE IN GROUP HEALTH INSURANCE OF THE COMPANY IN INDIA

a.
b.
c.
Sr. No.
Experience in conceptualizing, designing and implementing large healthcare schemes and have at least three year experience in catering to health insurance of 10,00,000 families across the country or more underwritten under each group health insurance policy in the financial year 2008-2009, 2009-2010 and 2010-2011 on State / Pan India basis. Number of beneficiary families means enrolled under Group Health Insurance Scheme. Insurers having Coinsurance for the purpose of risk sharing shall not qualify under the scheme.
Name of the Group Health Insurance Scheme Name of the State Policy peri od Number of enrolled Families Number of enrolled beneficiary families Premium (in Rs.) Per Total Family Premium (Rs.) (Rs in Lakh) Clai ms Recei ved (no.)
Settled/ Under Process (Rs in Lakh )
1 2008-09 1 2 3 2009-10 1 2 3 2010-11 1 2 3
DATE: Seal
AUTHORIZED SIGNATORY
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ANNEXURE 3
NAME AND ADDRESS OF THE INSURANCE COMPANY
DECLARATION
(ON BOND PAPER OF RS. 100)
BY THE INSURANCE AGENCY I, __________________________________________________________ Designated as ___________________________________________at_______________________ _____ of ______________________________________________ Insurance Company hereby declare that Our Insurance Company has not been black listed/debarred by any State Government/Central Government or its agencies or not disqualified in participating the Government schemes as per IRDA guidelines. DATE:
Stamp:
SIGNATURE
Name: Designation Address:
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ANNEXURE-3A
DECLARATION
BY THE INSURANCE AGENCY I, __________________________________________________________ Designated as ________________________________________at__________________________ __ of ______________________________________________ Insurance Company hereby declare that the Insurer will establish inhouse system to provide all such facilities elaborated under the scheme.
DATE:
Stamp:
SIGNATURE
Name: Designation:
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ANNEXURE 4
DECLARATION
BY THE INSURANCE AGENCY
I, __________________________________________________________ Designated as ________________________________________at__________________________ __ of ______________________________________________ Insurance Company hereby declare that I have read the contents of the RFP Document consisting of Part I to IV and having explicit agreement to adhere with the details of the scheme as mentioned in the RFP for implementation of the RGJAY given therein. I hereby submit the Proposal in the desired format with respective proformas duly signed by me. If our Proposal is found successful, the company is agreeable to execute the MoU within twenty four hours (excluding public holidays) after the award.
DATE:
Stamp:
SIGNATURE
Name: Designation: Address:
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ANNEXURE 5
UNDERTAKING
BY THE INSURANCE AGENCY

I,________________________________________________________designated
as ________________________________at_________________________________ _____ of ___________________________________ Insurance Company __________ hereby give an undertaking that the Proposal has been submitted as a single entity and has not formed any consortium with other Insurance Agencies under RGJAY scheme.
DATE:
Stamp:
SIGNATURE
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ANNEXURE 6 TAILOR MADE POLICY OF THE DESIRED HEALTH INSURANCE SCHEME IN CONFORMITY TO THE BENEFITS AVAILABLE, EXCLUSIONS, CONDITIONS ETC.
DATE:
Stamp:
SIGNATURE
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ANNEXURE-7 OFFICE INFRASTRUCTURE IN THE STATE AND IN THE CONCERNED DISTRICTS. Office Number of Branches
All India (Numbers)
State ( Numbers) Gadchiroli Amravati
Number of Branches Mumbai City Mumbai Suburban Solapur Nanded Raigad Dhule
Head Office Zonal Offices Operating Offices
DATE:
Stamp:
SIGNATURE
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ANNEXURE-8 ACTIVITY CHART Activity Identifying the Project Officer Setting up of Project Office with infrastructure in the area of Municipal Corporation of Greater Bombay Appointment of Medical Officers Establishment of other staff Preparatory meeting with hospitals Inspection of hospitals vis--vis scheme requirements, identification of Rajiv Gandhi Jeevandayee Medical Co-ordinator (MCO), Rajiv Gandhi Jeevandayee Medical camp Coordinator (MCCO), signing of MoU and Empanelment Of Hospitals Issue of CUG connections to MCO s and MCCO s Installation of kiosk, computer and Accessories and 1mbps connectivity. Printing and distribution of publicity Material Printing and distribution of stationary related to work flow of the scheme. Appointment of Aarogyamithras In PHCs/Govt. Hospitals In Network Hospitals Training of Aarogyamithras, distribution of Aprons and CUG mobiles. Training of Doctors Training of other staff IT enabling Establishment of 24 Hrs Call Center Establishment of other infrastructure Establishment of infrastructure in the districts Preparatory meetings and trainings at district level for inaugural mega camps.
Number of days required to complete the activity from the award date
Remarks
DATE:
Stamp:
SIGNATURE
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PLAN FOR HEALTH CAMPS
ANNEXURE-9
DATE:
Stamp:
SIGNATURE
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DETAILS OF EMPANELLED HEALTH FACILITIES WITH INSURERS

Dsitrict Name of Hospital Tertiary/ General Private/ Govt. No. of Empanelled Beds for specialized category/ies and procedures (Number/s)
ANNEXURE-10
1 2 3 4
Gadchiroli Amravati, Nanded, Solapur,
Dhule,
Raigad,
Mumbai Urban
Mumbai Suburban
Other Districts within Maharashtra
DATE:
Stamp:
SIGNATURE
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ANNEXURE -11 ANY OTHER INFORMATION
DATE:
Stamp:
SIGNATURE
~ 39 ~
SECTION C F INANCIAL PROPOSAL

A) Premium quote for a sum insured of Rs. 1.50 Lakh per family per annum on floater basis. (For renal implant the ceiling is Rs. 2.5 lakh): SR. NO. 1 PREMIUM PER FAMILY WITHOUT S.T. Rs. (Rs. in words) PREMIUM PER FAMILY WITH S.T . Rs. (Rs. in words)
B)
Details of Add on cover without any additional premium: Benefits Details
Sr. No. 1 2 3 4
Note: No other documents or attachments are permissible along with Section C. Any deviation will attract disqualification.
----------------------------------------DATE:
Stamp:
SIGNATURE
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Part IV: M o U (Memorandum of Unde rstanding) RAJIV GANDHI JEEVANDAYEE AROGYA YOJANA IN MAHARASHTRA. THE FIRST PHASE in 8 DISTRICTS OF GADCHIROLI, , AMRAVATI , NANDED, SOLAPUR, DHULE, , RAIGAD, MUMBAI CITY, MUMBAI SUBURBA DISTRICTS MEMORANDUM OF UNDERSTANDING This Memorandum of Understanding (hereinafter called the MoU) is executed at _________on this ____ day of ________ between the Government of Maharashtra/ Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) Society (the society is proposed to be incorporated prior to award of the contract) having its office at First Floor of Arogya Bhavan, St. Georges Hospital campus, Mumbai 400001 (hereinafter referred to as the Insured and Party of the first part) represented by Chief Executive Officer, Rajiv Gandhi Jeevandayee Arogya Yojana Society, which expression shall, unless repugnant to the context or meaning thereof, be deemed to mean and include its successors and permitted assigns; AND (Name of Insurance Company), an Insurance Company having its re gistered and Head Office at_______________________ Mumbai (hereinafter referred to as the Insurer and the Party of the second part) represented by Chairman cum Managing Director which expression, shall unless repugnant to the context or meaning thereof, be deemed to mean and include its successors and permitted assigns.
WHEREAS:
1. The Government of Maharashtra / Rajiv Gandhi Jeevandayee Arogya Yojana Society, a Nodal Agency has, after a due Selection process involving Technical and Financial Evaluation, awarded the Contract of Insurance under the Rajiv Gandhi Jeevandayee Arogya Yojana in 8 districts of Mumbai city, Mumbai Suburban District, Dhule, Raigad, Solapur, Nanded, Amravati, and Gadchiroli, of the State of Maharashtra for 30 identified specialized categories envisaging 972 identified procedures, to the Insurer and the Party of the second part. 2. The Insurer has agreed that they shall provide the health insurance services to the families of BPL(yellow ration card holders), Antyodaya, Annapurna and APL (orange ration card holders) belonging to eight Districts of Maharashtra under Phase -1 covered under Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) on the terms and conditions of the policy and more particularly described in this Agreement within the state of Maharashtra. 3. The commencement of Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) through the Insurer under this agreement shall be effective from 2 October 2011 [Date, Month and Year], for one year and shall expire on 1 October 2012 [Date, Month and Year]. 4. The Insurer has been registered under Section 3 of the Insurance Act 1938 (Act 4 of 1938) having its Registration No. ____ And is inter alia engaged in the business of providing General Insurance in India. 5. The Insurer has agreed to issue the Policy to the satisfaction and in favour of the Insured covering the Beneficiary families in the manner agreed herein. NOW THEREFORE IT IS AGREED as follows: 1. DEFINITIONS & INTERPRETATION 1.1 The following terms and expressions shall have the following meanings for purposes of this Agreement: i. Agreement shall mean this agreement and all Schedules, supplements, appendices, appendages and modifications thereof made in accordance with the terms of this agreement. ii. Benefit(s) shall mean the health services that the beneficiary families are entitled to receive based on the contract between the Government of Maharashtra and the Insurer under Rajiv Gandhi Jeevandayee Arogya
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iii.
iv. v. vi. vii. viii.
ix. x.
xi.
xii.
xiii.
xiv.
xv. xvi.
Yojana (RGJAY) subject to the terms, conditions, limitations and exclusions of the Policy. Beneficiary (ies) shall mean those existing families of BPL, Antyodaya, Annapurna and APL (except white ration card holders) belonging to Eight Districts of Maharashtra covered under Rajiv Gandhi Jeevandayee Arogya Yojana and enrolled under RGJAY. Business Day shall mean days on which commercial banks are open for business in India. Government of Maharashtra shall mean either, Government of Maharashtra or Rajiv Gandhi Jeevandayee Arogya Society nominated by the Govt. of Maharashtra. RGJAY shall mean Rajiv Gandhi Jeevandayee Arogya Yojana RGJAS shall mean Rajiv Gandhi Jeevandayee Arogya Yojana Society Claim Payment shall mean the payment of claim to the Empanelled Hospitals/Nursing Homes under the RGJAY based on the invoice/ Health card or yellow/Orange ration card transaction received by the insurer from the health providers and also it would include the payments made for reimbursement claims. De-Listing of Empanelled Hospitals/Nursing homes shall mean delisting the empanelled hospital by the Insurer based on the criteria defined. Empanelled Hospitals/Nursing Homes shall mean the Hospital/ Nursing Home as has been empanelled by the Insurer as per parameters defined in this agreement to provide health care services under Rajiv Gandhi Jeevandayee Arogya Yojana. Family mean members as listed on the Rajiv Gandhi Jeevandayee Arogya Yojana Health Cards or holding valid Orange/Yellow Ration Card. The details in the Health Card will be taken as the proof for determining the eligibility of the beneficiary. For those beneficiary families whom the health cards are not distributed, the beneficiary families will be identified based on names displayed on their valid Orange/Yellow Ration Card distributed by Department of Food and Civil Supplies coupled with Aadhar number or p hoto identity card issued by Govt. agency (driving license, election card) till he/she gets Aadhaar number. Force Majeure Event shall include: (i) Fire, flood, atmospheric disturbance, lightning, storm, typhoon, tornado, earthquake, washout, or other acts of God; (ii) War, riot, blockade, insurrection, acts of public enemies, civil disturbances, terrorism and sabotage and threats of such actions; (iii) Strikes, lock-outs, or other industrial disturbances or Labour disputes IRDA shall mean the Insurance Regulatory and Development Authority established under the Insurance Regulatory and Development Authority Act 1999. Insured shall mean the Government of Maharashtra /Rajiv Gandhi Jeevandayee Arogya Society (RGJAS) / Nodal Agency who has paid the premium on behalf of their beneficiary families to Insurer for availing the health insurance services under RGJAY. Insure r shall mean an Insurance Company selected by the Government of Maharashtra to provide all such services to the RGJAY beneficiary families as outlined in the agreement under RGJAY. Law includes all Statutes, Enactments, Acts of Legislature, Laws, Ordinances, Rules, Bye Laws, Clauses, Regulations, Notifications, Guidelines, Policies, and orders of any Statutory Authority constituted under the provisions of Constitution of India or Courts in India.
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Party shall mean either the Insurer or the Government of Maharashtra and Parties shall mean both the Insurer and the Government of Maharashtra. xviii. Period of Agreement shall mean that the agreement will be for three year from the effective date, xix. Period of Ins urance policy shall mean the period of one year from the inception date as notified during which the Insurance Policy shall be operative to provide the benefit to the RGJAY beneficiary families. xx. Project Office shall mean the office of the Insurer located at Mumbai to coordinates the provision of RGJAY under this Agreement. xxi. Policy shall mean the Health Insurance Policy of the Insurer issued to the Insured on behalf of the families of Below Poverty Line Population (yellow card holders), Antyodaya, Annapurna and Above Poverty Line Population (APL-orange ration card holders) belonging to eight Districts of Maharashtra under RGJAY. xxii. Policy Holder shall mean the Insured who has paid the premium on behalf of their beneficiary families to Insurer for availing the health insurance services under RGJAY. xxiii. Premium shall mean an amount agreed by both Parties charged per family on an annual basis as consideration for providing health insurance services under this Agreement. xxiv. Package Charges shall mean the indicative maximum charges per ailment/procedure for benefits including follow up package covered by this Agreement as fixed under Rajiv Gandhi Jeevandayee Arogya Yojana society. xxv. Provider shall mean empanelled Hospitals / Nursing homes under the scheme. xxvi. Scheme shall mean the Rajiv Gandhi Jeevandayee Arogya Yojana as operational and as otherwise outlined in this Agreement. Health Card shall mean Health Photo Card for RGJAY beneficiary families issued under RGJAY by the Insurer as per specifications given by Government of Maharashtra. xxvii. Service Area shall mean within state of Maharashtra basis within which the Government of Maharashtra has authorized the Insurer to provide health insurance service under RGJAY. 1.2 OTHERS i. Any grammatical form of a defined term herein shall have the same meaning as that of such term. ii. Headings are used for convenience only and shall not affect the interpretation of this Agreement. iii. Any reference to an agreement, contract, instrument or other document (including a reference to this Agreement) herein shall be to such agreement, instrument or other document as amended, supplemented or pursuant to the terms thereof. iv. Terms and expressions denoting the singular shall include the plural and vice versa. v. The term including shall always mean including, without limitation, for purposes of this Agreement. vi. The term herein, he reof, hereinafte r, hereto, hereunder and words of similar import refer to this Agreement as a whole. 2. BENEFICIARY FAMILIES: Families holding yellow ration card, Antyodaya Anna Yojana card (AAY), Annapurna card and orange ration card from eight districts viz. Gadchiroli, Amravati, Nanded, Solapur, Dhule,
xvii.
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Raigad, Mumbai city and Suburban Mumbai. The families with white ration card holding would not be covered under the scheme. The total number of beneficiary families in the state would be around 2,04,30, 527; out of which approximately 49 Lakh families in the 8 districts are to be covered under the scheme in first phase as on the date of publishing of the Request for Proposal (RFP) document. District wise profile of the beneficiary families is given below:
Districts Phase-I 1 2 3 4 5 6 7 8 Gadchiroli Amravati Nanded Solapur Dhule Raigad Mumbai City Mumbai Suburban Population 970294 2607160 2876259 3849543 1707947 2207929 3338031 8640419 *Approximate number of Beneficiary Families 182889 559473 543961 830011 397674 566231 482073 1340828
26197582 4903140 Total * Based on data furnished by Civil Supplies department as on 31.05.2010. The beneficiary families would be identified through the Rajiv Gandhi Jeevandayee Health Card issued by the Government of Maharashtra or based on the Yellow and Orange ration card issued by Civil Supplies Department. The following actions would be undertaken by Network hospitals in case of the possible exceptional situations:
No Exceptional Situation Requirement for benefit Aadhaar number and in case Aadhaar number not taken any Photo ID card issued by Govt. ( Driving license, election identity card with photograph) to No Health Card with beneficiary, but correlate the patient name & photograph Valid Yellow or Orange Ration Card (In instance of emergency admission, provisional with name of beneficiary is available preauthorization may be given subject to confirmation of it against submission of valid photo identity card issued by Govt. before discharge.) Children born after issue of card i.e. Photograph of child with either parent along with name and photo not available on Health card/ valid Yellow or Orange ration card of health card or on valid yellow/Orange either parent and Birth certificate issued by authorized ration card officer. Name is there in Yellow or Orange Not eligible for benefit package Ration Card and matches with name (The yellow /Orange ration card is cancelled after in photo identity. But the card is verification by department but still the family is invalid as it does not match with the holding it) digitized list.
3. COVERAGE: This is a package medical insurance scheme to cover hospitalization for surgeries and therapies through cashless treatment in respect of the following 30 identified specialized categories having 972 procedures and 121 follow up procedures along with follow up packages. GENERAL SURGERY 1 ENT SURGERY 2 OPTHALMOLOGY SURGERY 3 GYNAECOLOGY AND OBSTETRICS SURGERY 4 ORTHOPEDIC SURGERY AND PROCEDURES 5 SURGICAL GASTRO ENTEROLOGY 6 CARDIAC AND CARDIOTHORACIC SURGERY 7
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PEDIATRIC SURGERIES 8 GENITOURINARY SYSTEM 9 NEUROSURGERY 10 SURGICAL ONCOLOGY 11 MEDICAL ONCOLOGY 12 RADIATION ONCOLOGY 13 PLASTIC SURGERY 14 BURNS 15 POLY TRAUMA 16 PROSTHESES 17 CRITICAL CARE 18 GENERAL MEDICINE 19 INFECTIOUS DISEASES 20 PEDIATRICS 21 CARDIOLOGY 22 NEPHROLOGY 23 NEUROLOGY 24 PULMONOLOGY 25 DERMATOLOGY 26 RHEUMATOLOGY 27 ENDOCRINOLOGY 28 GASTROENTEROLOGY 29 INTERVENTIONAL RADIOLOGY 30 Detailed list of specified surgeries and therapies falling in the identified groups and packages is given Appendix I (a) and the follow up package is given Appendix 1 (b) of Part IV. The scheme would provide for cashless treatment to patients in the Network Hospitals in case of covered surgical procedures, interventions and therapies connected with the diseases /conditions mentioned above. 4. SUM ASSURED: The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary up to Rs. 1,50,000/- per family pe r year in any of the Empanelled Hospital/Nursing Home subject to Package Rates on cashless basis through Health cards. The benefit shall be available to each and every member of the family on floate r basis i.e. the total reimbursement of Rs. 1.5 lakh can be availed by one individual or collectively by all members of the family. In case of renal transplant surgery, the immunosuppressive therapy is required for a period of 1 year. So the upper price ceiling for Renal Transplant would be Rs. 2, 50,000 per operation as an exceptional package exclusively for this procedure. The cases are likely to be very few and well controlled by Human Organ Transplant Act 1994. This would also be part of the coverage. 5. PRE EXISTING DISEASES: All diseases under the proposed scheme will be covered from day one. A person suffering from any disease prior to the inception of the policy shall also be covered under approved procedures for that disease. 6. PRE AND POST HOSPITALIZATION: 6.1 From date of reporting to hospital up to 10 days from the date of discharge from the hospital shall be part of the package.
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Network Hospital will provide follow- up free consultation, diagnostics and medicines when patient is called for follow- up within 10 days of discharge being part of the package. 7. DEFINITION OF FAMILY: Family means members as enlisted and photographed on the Rajiv Gandhi Jeevandayee Arogya Yojana Health Cards or holding valid Orange/Yellow Ration Card. 8. HEALTH CARDS All eligible families in these districts shall be provided with Rajiv Gandhi Jeevandayee Arogya Yojana Health Cards in due course of time. These Health Cards will be used for identification of Beneficiary families in the family under the Scheme. Family Health Cards will be prepared by using data of valid ration cards (yellow and orange) issued by Food and Civil supplies department coupled with Aadhaar numbers issued by UID authorities, although the latter is individual card. As an interim measure till the health card is issued, the valid Orange/Yellow Ration Card with Aadhaar number or in case Aadhaar number not available, any Photo ID card of patient issued by Govt. agencies (Driving license, Election ID) would be required to correlate the patient name and photograph for identification of beneficiary. 9. WEB PORTAL: All activities related to the scheme shall be done through a dedicated portal of Rajiv Gandhi Jeevandayee Society, the development and maintenance cost of which will be borne by the Insurer. The source code and system design document for the application exclusively developed by Insurer for Rajiv Gandhi Jeevandayee Arogya Yojana shall be provided in good working condition to Rajiv Gandhi Jeevandayee Society. A dedicated data center in the name of Rajiv Gandhi Jeevandayee Yojana will be maintained by the Insurer. The proprietary rights of software will be with Government of Maharashtra .Patient records will be property of Rajiv Gandhi Jeevandayee Society. Confidentiality of patient records should be maintained. The web portal will be a repository of information and will have the following features and the respective workflows: 1. General Information on the scheme. 2. Details of patients reporting and referrals from the PHC / Rural/ Subdistrict/Women/General/District hospitals on daily basis. 3. E-Health Camps system and daily reporting of health camps. 4. Details of patients reporting and getting referred from the health camps. 5. E-Empanelment system. 6. Emergency approval system. 7. Call centre application. 8. Patient registration by Aarogyamithra in Network Hospitals. 9. Details of in-patients and out patients in the network hospitals. 10. On-bed reporting system. 11. Costing of the Tests done in the network hospitals. 12. E-preauthorization. 13. Surgery details. 14. Discharge details. 15. Real-time reporting, active data warehousing and analysis system. 16. Claim settlement. 17. Electronic clearance of bills with payment gateway. 18. Follow- up of patient after surgery. 19. Distribution of Follow-up medicines. 20. Rajiv Gandhi Jeevandayee Messaging Services. 21. Grievance and Feedback workflow. 22. Back Tracking System. 23. E-Office management. 24. Accounting system.
6.2
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25. TDS workflow. 26. Death reporting system. 10. PAYM ENT OF INSURANCE PREMIUM: It is agreed that Government shall pay to the Insurer an amount of Rs. ---------- Plus Service Tax as applicable, towards the entire annual premium etc. The payment shall be made in four installments of Rs. ------------------- Plus services tax each as under:. First Installment: Before the commencement of the scheme Second installment: Before the start of second quarter of year Third installment: Before the start of third quarter of year Fourth installment: Before the start of fourth quarter of year The total number of beneficiary families for each District is an indicative estimate and may vary. The number of the final beneficiary families for each district will be given within one month of signing MOU. The total premium payable would be based on this final figure of eligible beneficiary families. Following activities should be completed before inception of scheme within three months of award of contract before release of the first installment of the premium. 1) The successful insurer shall furnish the security deposit to the RGJAYS within 7 days from the date of communication of Award of Contract for an amount of 5% of the contract value, valid up to 90 days after the date of completion of warranty obligations and enter into MOU on Rs. 100/- non-judicial stamp paper. The cost of Stamp paper should be borne by the insurer. The Security Deposit should be in the form of Bank Guarantee in favour of the Rajiv Gandhi Jeevandayee Arogya Society' payable at Mumbai from any Nationalized or Scheduled bank. The Security Deposit will be discharged by the Purchaser and returned to the Supplier not later than 30 days following the date of completion of the Insurers performance obligations by the end of first quarter of execution of scheme, including the warranty obligation, under the MOU. The security deposit shall be discharged (forfeited) as a compensation for any loss resulting from the failure to perform the obligations under the MOU or in the event of termination of the MOU or in any event as the Purchaser thinks fit and proper. 2) The Insurance Company has to empanel minimum 100 network hospitals in the state and it should be ensured that all procedures should be covered cumulatively in empanelled hospitals. 3) The Insurance Company has to start call center with all requisite staff, departments and appointment of field staff with staff at network hospital. An adequate area should be reserved for office of Rajiv Gandhi Jeevandayee Arogya Yojana Society office. Software (if so specifications and certifying authority) and Connectivity should be established in order to start the scheme. 11. PERIOD OF INSURANCE & PERIOD OF AGREEMENT: The insurance coverage under the scheme for the beneficiary families shall be in force for a period of one year from the date of commencement of the policy (From 0.00 hrs of 02.10.2011 to Midnight of 01.10.2012 for Phase-I). The period of agreement shall be for three years with effect from 02.10.2011; subject to annual review and renewal of policy based on performance parameters as below. 1. Percentage of health camps in a month (One health camp per week) 2. Claim ratio 3. Number and Percentage of complaints redressed against total complaints received. 4. Minimum number hospitals to be empanelled at start of scheme 100. 5. Time required for preauthorization 12 hours ordinarily and immediately in cases of emergency. 6. Time required for claim settlement. 7. IEC Activities according to norms fixed.
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8. Any new issue coming up in fulfillment of objective of RGJAY Society / GOM. 11.a. PERFORMANCE PARAMETERS AND PENALTY CLAUSE: The Insurer is required to perform multiple activities in performance of its obligations arising out of the insurance contract to it. Any activity not performed by the insurer within the given time line shall hamper implementation of Rajiv Gandhi Jeevandayee Health Insurance Scheme from the planned date. Such activities have been listed here under which the successful bidder is required to complete within the specified period from the date of award of the insurance contract to it failing which a penalty as specified percentage on total premium against each section per week/month shall have to pay to the RGJAY society for the period of delay.
Sr. No Activity Time frame fro m the date of Signing of Agreement 7 days 30 Days 3 month 3 months Penalty for the delay in execution in % of component charges 1% 1% 1% 2.0%
PENALTY PER WEEK A a. Identifying the Project Officer b. Setting up of Project Office with in frastructure Municipal Corporation of Greater Bo mbay B Preparation and Certificat ion of software on receiving the specification fro m Society. C Dedicated Website as per the requirement (envisaging Empanelment MIS,HR M IS, Publicity and Camp MIS, Eauthorization MIS, Claim MIS, Follow up monitoring MIS, Field operations Support service MIS, Grievance MIS, Medical Audit MIS, Key performance Indicators and vari able salary, Operat ion maintenance MIS) D Establishment of 24 Hrs. Call Center and Establishment of other infrastructure E Establishment of sufficient infrastructure in each district. Installation of kiosk, co mputer and accessories etc. F G To identify the Hospital Network Providers and networking with them.
3 month 3 month 3 months
1% 1% 0.5% 0.5%
H I
To arrange cashless treatment of the insured in the 3 months empanelled hospitals under the scheme and facilitation of proper networking for quick and error-free processing of pre-authorizat ions. To provide adequate manpower, so as to ensure free flow of 3 months daily MIS and ensure that progress of scheme is reported to Society in the desired format on a real-time basis. Preparation of various formats used for cashless 1 months transactions, discharge summary, billing pattern and other reports in consultation with the Govern ment. PENALTY PER MONTH Processing of claims related to the scheme. Pre-authorization of System to be ready requests and approval of preauthorization if all the conditions are in 3 months fulfilled, within 12 hours of receiving the preauthorization (Continuing request from the network provider if failure % is more than activity) 5%) Scrutinize the b ills fro m n et wo rk hosp it als an d give System to be ready approval for the sanction of the bill and forward payment in 3 months & within 7 working days on receipt of complete claim document (Continuing from the Network Hospitals. (Failure % is more than 5%) activity) Medical Auditing (by minimu m qualificat ion MBBS) fo r conducting 20% per month concurrent audits of services and quality of service provided to the beneficiary families delivered by Network Hospitals on periodic basis as well as and required. 3rd month (Continuing activity)
0.5% 0.5%
1%
1%
0.5%
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Sr. No M
Activity
Time frame fro m the date of Signing of Agreement 3rd month onwards
Penalty for the delay in execution in % of component charges 0.5%
HR Nu mber of network hospitals and number of Aarogymitras /Medical Coordinators, Camp Coordinators posted- District wise, month wise, and aggregate Nu mber of Public facilit ies (CHCs/PHCs) and number of Aarogymitras posted - District wise, month wise, and aggregate Training programme for Network Hospital Providers and other stake holders ones in a month.
2nd month onwards

(Continuing activity)
0.5%
12. ADJUSTMENT/ REFUND OF PREMIUM: If there is a surplus after the claims experience on the premium (excluding Service Tax) at the end of the policy period, after providing 20% of the premium paid towards the Companys administrative cost, of the balance 80% after providing for claims payment and outstanding claims, 90% of the left over surplus will be refunded to the Government of Maharashtra / Rajiv Gandhi Jeevandayee Arogya Yojana Society within 30 days after the expiry of the Runoff period. 13. PROCEDURE FOR ENROLLMENT OF HOSPITALS: The Public and Private Hospitals will be jointly empanelled within the State of Maharashtra by Rajiv Gandhi Jeevandayee Arogya Yojana Society and Insurance Company following the empanelment procedure laid down by Rajiv Gandhi Jeevandayee Arogya Yojana Society. The hospitals having minimum of 50 inpatient hospital beds with adequate facilities and offering the services as stipulated below shall be empanelled after being scrutinized and recommended by the Empanelment and Disciplinary Committee. Empanelment and Disciplinary Committee will constitute a subcommittee of four doctors for this purpose. Two doctors will be nominated by Insurance Company and two by Rajiv Gandhi Jeevandayee Arogya Society. The purpose of this empanelment is to ensure capability of the hospital to provide some of the identified 30 specialized categories and seek agreement to the equal or lower price for these 972 procedures and 121 follow up procedures and take an opportunity to assess the current quality of care therein. It would be the responsibility of the Insurer for enrollment of Network Hospitals in the State of Maharashtra to give adequate facilities for the treatment of the patients when they present themselves. The number of empanelled hospitals and number of procedures in each hospital to be permitted will be based on the need and at discretion of the society in the interest of beneficiary. Network hospitals are supposed to extend medical aid to the beneficiary under the scheme. Procedure for enrollment of Hospitals is placed as Appendix- IV of Part IV. Preference for empanelment could be given to the hospitals accredited under National Board of Accreditation for Hospitals. It is also desired to accreditate the empaneled hospital under National Board of Accreditation for Hospitals in order to ensure quality of care. 14. MOU with Network Hos pital and Disciplinary actions against the hos pitals: (i) MOU with Network Hospital: The Insurer shall sign MOU with all the network hospitals to be empanelled under the scheme. Separate MOUs with relevant provisions have to be entered into for Multispeciality, Cancer Treatment etc. This MOU is subject to the approval of the Rajiv Gandhi Jeevandayee Society. Number of empaneled hospitals and specializations will depend on the benefit the beneficiary. Network hospitals are supposed to extend medical aid to the beneficiary under the scheme. A provision will be made in MOU regarding noncompliance / default clause. Such matter shall be looked in to by the Empanelment and Disciplinary Committee, the decision of which will be binding to all concerned. The sample MOU is attached as appendix 7 of Part IV.
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(ii) Disciplinary actions against the hospitals: On recommendation by the Empanelment and Disciplinary Committee the Insurer shall take various disciplinary actions against Network Hospital including De-listing from the empanelment if it is found that guidelines of the Scheme are not followed by it and services offered are not satisfactory as per laid down standards. Hospital may also be delisted or de-empanelled if infrastructure in the hospital is found below the standards laid down by society any time during the policy period. The Insurer is also liable for any deficiency in the service provided by the network hospital / service provider other than medical services and in case of any delisting the Insurer shall find alternative immediately. 15. CASHLESS SERVICE: The Insurer has to ensure that adequate facilities are provided to all beneficiary families so that they do not have to pay any deposits at the commencement of the treatment or at the end of treatment to the extent the Services as covered under the Rajiv Gandhi Jeevandayee Arogya Yojana. It is envisaged that for each hospitalization the transaction shall be cashless for covered procedures. Enrolled/Eligible beneficiary along with health card/ orange or yellow ration card will go to hospital and come out without making payment to the hospital subject to procedure covered under the scheme. The same is the case for diagnostics if eventually the patient does not end up in undertaking the surgery or therapy. The beneficiary has right to select network hospital and services of selected network hospital should be made available. (Subject to availability of beds) In instance of non availability of beds in network hospital, cross referral to another network hospital may be accepted. 16. PACKAGES: The insurer should ensure that the Network hospitals follow the packages worked out by Rajiv Gandhi Jeevandayee Society. The package rates will include bed charges in General ward, Nursing and boarding charges, Surgeons, Anesthetists, Medical Practitioner, Consultants fees, Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Med icines and Drugs, Cost of Prosthetic Devices, implants, X-Ray and Diagnostic Tests, food to impatient, one time transport cost etc. In other words the package should cover the entire cost of treatment of patient from date of reporting to his discharge from hospital and 10 days after discharge after surgery including complications if any, making the transaction truly cashless to the patient. In instance of death, the carriage of dead body from network hospital to the village/township would also be part of package. 17. IMPLEMENTATION PROCEDURE: The entire scheme is to be implemented as cashless hospitalization arranged by the insurer. The following table steps represent the process flow of treatment to the beneficiary in the Network hospital. The Entire scheme is to be implemented as cashless hospitalization arranged by the Insurance Company. The following table represents the process flow of treatment to the beneficiary A) Process Flow of the Beneficiary Treatment in the Network Hospital Step I Beneficiary families shall approach nearby PHC/Rural, Sub district, General, Women/District Hospital/Network Hospital. Aarogyamitras placed in the above hospitals s hall facilitate the beneficiary. If beneficiary visits Government Health Facility other than the Network Hospital, he/she will be given a referral card to the Network Hospital with preliminary diagnosis by the doctors. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the Villages and can get that referral card based o n the diagnosis. The information on the outpatient and referred cases in the PHC/Rural, Sub district, General, Women/DH and the camps will be collected from all Aarogyamitras/Hospitals on regular basis and captured in the dedicated database through a well-established call center.
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Step 2 The Aarogyamitras at the Network Hospital examine the referral card and health card or Yellow/Orange Ration Card, register the patients and facilitate the beneficiary to undergo specialist consultation, preliminary diagnosis, basic tests and admission process. The information like admission notes, test done will be captured in the dedicated database by the Medical Coordinator of the Network Hospital as per the requirement of the Rajiv Gandhi Jeevandayee Arogya Yojana Society. Step 3 The Network Hospital, based on the diagnosis, admits the patient and sends Epreauthorization request to the insurer, same can be reviewed by Rajiv Gandhi Jeevandayee Arogya Yojana Society. Step 4 Recognized Medical Specialists of the Insurer and Rajiv Gandhi Jeevandayee Arogya Yojana Society examine the preauthorization request and approve preauthorization, if, all the conditions are satisfied. This will be done within 12 working hours and immediately in case of emergency wherein e-preauthorization is marked as EM. Step 5 The Network Hospital extends cashless treatment and surgery to the beneficiary. The Postoperative notes of the Network Hospitals will be updated on the website by the medical coordinator. Step 6 Network Hospital after performing the covered surgery/ therapy/ procedure forwards the Originals bills, Diagnostics reports, Case sheet, Satisfaction letter from patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to Insurer for settlement of the claim. The Discharge Summary and follow-up details will be part of the Rajiv Gandhi Jeevandayee Arogya Yojana Society portal. Step 7 Insurer scrutinizes the bills and gives approval for the sanction of the bill and shall make the payment within agreed period. The claim settlement module along with electronic clearance and payment gateway will be part of the workflow in Rajiv Gandhi Jeevandayee Arogya Yojana Society portal and will be operated by the Insurer. The reports will be available for scrutiny on the Rajiv Gandhi Jeevandayee Arogya Yojana Society login. Step 8 The Network Hospital will provide free follow-up consultation, diagnostics, and medicines under the scheme up to 10 days from the date of discharge. 18. HEALTH CAMPS: Health Camps are to be conducted in Taluka Head Quarters, Major Gram Panchayats and Municipalities. Minimum of one camp per week per empanelled hospital has to be held in the eight districts in the policy year. The insurer shall ensure that at least one free medical camp is conducted by each network hospital per week at the place suggested by Rajiv Gandhi Jeevandayee Society. The Rajiv Gandhi Jeevandayee Medical Camp Coordinator (MCCO) of the hospital shall coordinate the entire activity. Network hospital shall carry necessary screening equipment along with specialists (as suggested by the Rajiv Gandhi Jeevandayee Society) and other paramedical staff. The Insurer shall put in the minimum requirements as regards the health camp in the MOU with the hospitals. They shall work in close liaison with district coordinator of the Insurance Company, Civil Surgeon/DHO in consultation with District Collector. Hospital shall follow the Camp policy of Rajiv Gandhi Jeevandayee Society The Insurer shall in consultation with Rajiv Gandhi Jeevandayee Arogya Yojana Society plan, prepare and inform the schedule of Health Camps well in advance to Rajiv Gandhi Jeevandayee Arogya Yojana Society as per the guidelines and also inform the same to the
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District Collectors, Civil Surgeons/DHO, Public Representatives, Empanelled hospitals and other stakeholders. The Insurer shall ensure that Network Hospital conducts the Camp as per schedule with all necessary equipment and professionals in the concerned fields. They should also submit to Rajiv Gandhi Jeevandayee Arogya Yojana Society the confirmation of participation in the camps from the Network Hospital. The Network hospital shall enter the details of the patients screened and referred in the camps in the assigned login of the workflow of Rajiv Gandhi Jeevandayee Arogya Yojana Society Portal. 19. DISTRICT LEVEL CO-ORDINATION: District level offices with necessary infrastructure have to be setup by the Insurance Company. The Insurer needs to have district level monitoring staff with District Coordinators, GMs/DGMs /Area Managers /Assistant Area Managers /District level doctors / Regional Coordinators of the Insurance Company ( When scheme) is implemented in whole state) should monitor Aarogymitras, co-ordinate with network hospital, district administration and peoples representatives for effective implementation of programme. They should ensure that camps are held as per schedule, arrange for canvassing for the camp, mobilize patients and follow up the beneficiary families. He/she should work in close liaison with district administration under the supervision of District Collector. He should also ensure proper flow of MIS and report to society on day to day basis about the progress of the scheme in the district. The Insurance Company should ensure that dedicated staff is made available for the scheme. There shall be at least one doctor to be placed in each district. Further wherever the concentration of the Network Hospitals is more additional doctors need to be placed. The Insurance Company shall follow the instructions of Rajiv Gandhi Jeevandayee Arogya Yojana Society in this regard. 20. IN-HOUSE SYSTEM: The Insurer will establish inhouse system to provide all such facilities elaborated under the scheme. The Insurer will submit detailed list of staff appointed to Rajiv Gandhi Jeevandayee Arogya Yojana Society with their designations, responsibilities and contact numbers before the commencement of policy. 21. PROJECT OFFICE AND STATE LEVEL CO-ORDINATION: The Project Office of the Insurer shall be separately established in the jurisdiction of Municipal Corporation for Greater Bombay for better coordination with the Rajiv Gandhi Jeevandayee Society and would also provide adequate space for society. The project office shall report to the Rajiv Gandhi Jeevandayee Arogya Yojana Society on a daily basis in the prescribed proformas. The following departments shall be established by the Insurer in the Project Office. i. 24 Hour call ce ntre with toll free help line : The Insurer should nominate within 5 days of award of MOU responsible officer / officers to properly coordinate work and ensure proper implementation of scheme up to the satisfaction of Rajiv Gandhi Jeevandayee Society. It should review the progress with Rajiv Gandhi Jeevandayee Arogya Yojana Society on day to day basis and be responsible to implement the suggestions of Rajiv Gandhi Jeevandayee Arogya Yojana Society for effectively running the scheme. The Insurer shall provide telephone services for the guidance and benefit of the beneficiary families whereby the Insured Persons shall receive guidance about various issues by dialing a State Toll free number. Call Centre Information: The Insurer shall operate a call centre for the benefit of all Insured Persons and for real-time reporting. The Call Centre shall function for 24 hours a day, 7 days a week and round the year. The Insurer undertakes to provide services to the Insured Persons in Marathi, English and Hindi. The Insurer will operate a state toll free number with a facility of a minimum of 10 lines. The cost of operating of the Toll free telephone number shall be borne solely by the Insurer. The Insurer will intimate the state toll free number to all beneficiary families along with addresses and other telephone numbers of the Insurers Project Office. The action taken on
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every call will be routed through an escalation matrix which ends at the level of CEO of the Rajiv Gandhi Jeevandayee Society. As a part of the Call Centre service the Insurer shall provide the following: a. Answers to queries related to Coverage and Benefits under the Policy. b. Information on Insurers office, procedures and products related to health. c. General guidance on the Services. d. For cash-less treatment subject to the availability of medical details required by the medical team of the Insurer. e. Information on Network Providers and contact numbers. f. Benefit details under the policy and the balance available with the Beneficiary families. g. Claim status information. h. Advising the hospital regarding the deficiencies in the documents for a full claim. i. Medical and health related queries to be addressed by medical officer in the call center. j. Any other relevant information to the Beneficiary families including grievances. k. Any information required from the field for the Insurer. l. Any related service to the beneficiary families. m. Detailed MIS from Aarogyamithras in Government Hospitals / Network Hospitals and Camps. n. Any related Service as directed by Rajiv Gandhi Jeevandayee Arogya Yojana Society from time to time. ii) MIS Department to collect, collate and report data on a real-time basis. This department will also have to submit with operators who collect hourly information from the Aarogyamthras, regional coordinators, district coordinators etc. Based on this the reverse flow of dissemination of information shall also take place. There shall be reports for each district. The MIS department shall also follow- up the cases at all levels. The department shall also generate reports as desired by Rajiv Gandhi Jeevandayee Society. iii) Field Operations Department to coordinate the daily activities of field staff. The operations of the field department shall be monitored online. iv) HR Department to manage human resources for the scheme and maintain online database of staff and their management details. v) Training Department for capacity building of all stakeholders and staff. vi) Publicity and logistics Department to undertake all the publicity and logistics activities as specified by Rajiv Gandhi Jeevandayee Society. vii) IT Departme nt to ensure that the website with e-preauthorization, claim settlement and real-time follow-up is maintained and updated on a 24-hour basis. There should be inbuilt anonymity of name of network hospital and health card number in the software while giving preauthorization and claim settlement. The proprietary rights of software will be with Government of Maharashtra after three years. Patient records will be property of Rajiv Gandhi Jeevandayee Society. Confidentiality of patient records should be maintained. viii) Round-the-clock Pre-authorization Departme nt with specialist doctors for each category of diseases shall work round the clock along with Rajiv Gandhi Jeevandayee Arogya Yojana Society doctors to process the preauthorization within 12 working hours and immediately in cases of emergency. ix) Claims settlement Departme nt with electronic clearance facilities. x) Health Camp Department to plan, inform, implement and follow-up the camps as per the directions of Rajiv Gandhi Jeevandayee Society.
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Grievance Department to be manned by doctors and othe r staff to address the grievances from time to time as per the instructions of Rajiv Gandhi Jeevandayee Society. The insurer shall act as a frontline for the redressal of Beneficiary families / Network Hospital grievances. The Insurer shall also attempt to solve the grievance at their end. The grievances so recorded shall be numbered consecutively and the Beneficiary families / Network Hospital shall be provided with the number assigned to the grievance. The Insurer shall provide the Beneficiary families / Network Hospital with details of the followup action taken as regards the grievance as and when the Beneficiary families require it to do so. The Insurer shall also record the info rmation in pre-agreed format of any complaint / grievance received by oral, written or any other form of communication. Action Taken Report for Customer Grievance: The INSURER shall record in detail the action taken to solve the grievance of the Beneficiary families / Provider in the form of an Action Taken Report (ATR) within 2 working days of the recording of the grievance and imme diately in case of emergencies . The Insurer shall provide the society / Government with the comprehensive action taken report (ATR) on the grievances reported in pre-agreed format. The entire process will be done through the call center and Rajiv Gandhi Jeevandayee Arogya Yojana Society portal. The Insurer shall co-ordinate with Provider / Rajiv Gandhi Jeevandayee Arogya Yojana Society in order to solve the grievance as and when required by the nature and circumstances of the grievance. xii) Follow-up Department to coordinate the follow-up consultation and distribution of drugs as per the instructions of Rajiv Gandhi Jeevandayee Society. xiii) Empanelment Departme nt to empanel the hospitals in the network as per the guidelines given by Rajiv Gandhi Jeevandayee Arogya Yojana Society and monitor the compliance. xiv) Feedback department to send feedback formats, collect and analyses feedback of the patients as per the directions of Rajiv Gandhi Jeevandayee Society. The department will also document each case and upload the same in the society portal. The INSURER shall also collect the satisfaction slip from the Beneficiary families at the time of discharge who had obtained the cashless services. The Beneficiary families shall submit the Satisfaction slip issued by the INSURER at the time of discharge through Provider. The INSURER shall also carry out the Customer Satisfaction Survey regularly by using the rating card for the purpose. xv) Administration Department for office management. xvi) Vigilance Department for keeping vigil on all service providers and staff. xvii) Legal Departme nt exclusively for the project. xviii) Accounts Department. xix) Other departme nts required for office work. 22. AAROGYAMITRAS: i) Aarogyamithras in Rural / Sub district / Wome n Hospitals / Government Hospitals etc. The unique nature of the scheme demands the Insurer to appoint Aarogyamithras in consultation with Rajiv Gandhi Jeevandayee Arogya Yojana Society in all Rural / Sub district / Women Hospitals / Government Hospitals for propagating the scheme, mobilizing people for health camps, counseling beneficiary families, facilitating the referral / treatment of these patients and follow- up. For effective and instant communication all the Aarogyamithras will have to be provided with cell phone CUG
xi)
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connectivity by the Insurer. The Insurer will provide uniform (White apron with scheme logo) to all the Aarogyamithras and ensure that they wear it when on duty. ii) Aarogyamithras in Network Hos pitals: The Insurer also needs to appoint minimum three Aarogyamithras at all network hospitals to facilitate admission, treatment and cashless transaction of patient. The Aarogyamithras should also help hospitals in preauthorization and claim settlement. They should also ensure proper reception and care in the hospital and send regular MIS. The Aarogyamithras will also ensure cashless followup consultation and facilitate collection, stock maintenance and distribution of follow-up medicine in coordination with pharmacist. For effective and instant communication all the Aarogyamithras will have to be provided with cell phone CUG connectivity by the Insurer. The Insurer will provide with uniform (White apron with scheme logo) to all the Aarogyamithras and ensure that they wear it when on duty. The Insurer shall ensure that prefabricated Aarogyamithra kiosks with all additional requirements as per the design approved by Rajiv Gandhi Jeevandayee Arogya Yojana Society is put up in all hospitals. The role of Aarogyamithra can be modified by the society from time-to-time. The Insurer will provide uniform and arrange the workshops / training sessions for the Aarogyamitras on the guidelines specified by Rajiv Gandhi Jeevandayee Society. The detailed note on Aarogyamitras and their role is enclosed at Appendix III of Part IV. 23. WEB PORTAL: All activities related to the scheme shall be done through a dedicated portal of Rajiv Gandhi Jeevandayee Society, the development and maintenance cost of which will be borne by the Insurer. The source code and system design document for the application exclusively developed by Insurer for Rajiv Gandhi Jeevandayee Arogya Yojana shall be provided in good working condition to Rajiv Gandhi Jeevandayee Society. A dedicated data center in the name of Rajiv Gandhi Jeevandayee Yojana will be maintained by the Insurer. The web portal will be a repository of information and will have the following features and the respective workflows: (Who will prepare) 1. General Information on the scheme. 2. Details of patients reporting and referrals from the PHC / Rural/ Subdistrict/Women/General/District hospitals on daily basis. 3. E-Health Camps system and daily reporting of health camps. 4. Details of patients reporting and getting referred from the health camps. 5. E-Empanelment system. 6. Emergency approval system. 7. Call centre application. 8. Patient registration by Aarogyamithra in Network Hospitals. 9. Details of in-patients and out patients in the network hospitals. 10. On-bed reporting system. 11. Costing of the Tests done in the network hospitals. 12. E-preauthorization. 13. Surgery details. 14. Discharge details. 15. Real-time reporting, active data warehousing and analysis system. 16. Claim settlement. 17. Electronic clearance of bills with payment gateway. 18. Follow- up of patient after surgery. 19. Distribution of Follow-up medicines. 20. Rajiv Gandhi Jeevandayee Messaging Services. 21. Grievance and Feedback workflow. 22. Back Tracking System. 23. E-Office management.
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24. Accounting system. 25. TDS workflow. 26. Death reporting system. 24. ONLINE MIS AND E-PREAUTHORISATION: The Insurance Company should post enough dedicated staff, so as to ensure free flow of daily MIS and ensure that progress of scheme is reported to society in the desired format on a realtime basis. The company should establish proper networking for quick and error- free processing of pre-authorizations. The pre-authorization has to be done round the clock in co-ordination with Rajiv Gandhi Jeevandayee Arogya Yojana Societies. By a team of doctors from the Rajiv Gandhi Jeevandayee Arogya Yojana Society and Insurance Company. The preauthorization team shall have all the specialists concerned with the procedures covered in the scheme on a permanent basis. Rajiv Gandhi Jeevandayee Arogya Yojana Society will provide necessary specialists and technical committees to evaluate special cases from time-totime. Rajiv Gandhi Jeevandayee Arogya Yojana Society will provide necessary specialists to evaluate special cases. A technical committee consisting of specialist from Government Sector nominated by Rajiv Gandhi Jeevandayee Society in the concerned field, CMO of the Insurer and the Project Manager of the Insurer will evaluate and recommend to the CEO of Rajiv Gandhi Jeevandayee Society. The final decision on all the preauthorization would rest with the CEO of Rajiv Gandhi Jeevandayee Arogya Society. There should be inbuilt anonymity of name of network hospital and health card number in the software while giving preauthorization and claim settlement. 25. MEDICAL AUDITORS: The Insurer Company shall appoint enough number of medical auditors who does preauthorization in consultation with Rajiv Gandhi Jeevandayee Society. The Insurer shall also recruit specialized doctors for regular inspection of hospitals, attend to complaints from beneficiary families directly or through Aarogyamithras for any deficiency in services by the hospitals and also to ensure proper care and counseling for the patient at network hospital by coordinating with Aarogyamithras and hospital authorities. 26. PUBLICITY: The Insurance Company on its part should ensure that proper publicity is given to the scheme in all possible ways. This will include publicity on electronic and print media, distribution of brochures, banners, display boards etc. in public at appropriate places in consultation with RGJAYS. The spending on this activity should be two percent of premium amount. They shall also effectively use services of Aarogyamitras and district Coordinators for this purpose. They shall effectively use services of Aarogyamitras and district Coordinators for this purpose. Insurer will give wide publicity through and shall submit time bound programme: i. Guidebook: The Insurer shall handover the guidebook and related information to the Beneficiary families through the district administration in regional language- Marathi. The Guidebook will inter-alia contains information regarding the following: Information regarding the Insurer and its address, fax number, website address and other contact information. Toll free number of the Call Centre Service. List of Network Providers. Information on symptoms of the diseases / systems covered along with diagrammatic representations. Information on follow- up required. Information on possible preventive and curative measures.
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Procedure to be followed by the Beneficiary families for availing the Hospitalization Service as Cashless Access Service. Information regarding the Policy and Benefits. ii. Theatre Sliders iii. Publicity by Rajiv Gandhi Jeevandayee Help Desk at the PHCs / Rajiv Gandhi Jeevandayee Assistance Counters at Network hospitals. CAPACITY BUILDING: I. The Insurer will arrange the workshops / training sessions for the capacity building of the society personnel, their representatives and other stakeholders in respect of specific field of insurance at each district on the convenience of the society. Insurer will ensure that workshops and medical camps are organized in association with the network hospitals. II. The help of NGOs/SHGs will be taken by the Rajiv Gandhi Jeevandayee Help Desk / Rajiv Gandhi Jeevandayee Assistance Counters to spread awareness and guide the prospective patients to the network hospitals. The Insurer will associate in this task. RAJIV GANDHI JEEVANDAYEE MANUAL Rajiv Gandhi Jeevandayee Arogya Yojana Society will publish a detailed Manual for the Scheme titled Rajiv Gandhi Jeevandayee Arogya Yojana Manual consisting of all operational guidelines and details of the scheme. Rajiv Gandhi Jeevandayee Arogya Yojana Society may update and modify these guidelines and operational details as per the requirement of the scheme. The insurer has to follow the guidelines and instructions given in the manual while implementing the scheme. 27. SERVICING OF OTHER SCHEMES: Rajiv Gandhi Jeevandayee Arogya Yojana Society reserve the right to request the Insurer to extend services for processing of claims generated through any other scheme implemented by Rajiv Gandhi Jeevandayee Society. 28. ACTIVITY CHART: The activity chart submitted by the Insurer as part of the Proposal document and accepted by Rajiv Gandhi Jeevandayee Arogya Society (Appendix-IV) will be followed by the Insurer to take up the activities as narrated in the scheme and MOU. (In appendix time frame to be given instead of mentioning before commencement of scheme. This will help in monitoring the process) 29. ASSISTANCE FROM THE GOVERNMENT: The Government will on their part render all possible assistance viz. i. To give all necessary support for organizing sensitization programmes for the PHCs and Government Hospitals. ii. To provide financial assistance for health camps by network hospitals (@ Rs. 5000 per camp) ii. To extend necessary support in providing space and other support for locating Rajiv Gandhi Jeevandayee Help Desks at PHCs / other Government Hospitals. iii. To provide necessary professionals for technical committee. 30. CLAIMS PROCEDURE: The beneficiary families would be identified by the Rajiv Gandhi Jeevandayee Health card/ at the PHC / Government Hospital level/ Rajiv Gandhi Jeevandayee Assistance Counters in the network hospital. A self-declaration by the beneficiary /patient prior to hospitalization for the covered treatment that he does not belong to any of the excluded categories may be required. The family member having Health card will be referred to Network Hospital on recommendation of the Doctors at these centers. The insurer will make payment of the claims directly to the hospital. Payments will be made to the hospitals within 07 days after the receipt of all documents. The cost of various tests conducted on health card holders for covered procedures who ultimately do not undergo surgery, will be included in the insurance cost. Insurer will ensure that such test are done free of cost to the patient . The claims procedure
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will be carried in the electronic platform of Rajiv Gandhi Jeevandayee Arogya Yojana Society portal. The payment to the Network Hospital will be made online through electronic clearance. The procedure of processing of the claims will be handled by the project office of the insurer. The claims procedure will be under taken as detailed below: i) Claim Intimation The INSURER shall receive claim intimation from the Network hospital online in the form as agreed under the scheme. Rajiv Gandhi Jeevandayee Society portal will have reports indicating claim intimations received. ii) Collection of Claim docume nts The INSURER shall offer single window service at the respective Project office to the Network hospital for receiving the claim documents. In case of pre-authorization for the Cashless Service, the Network hospital will send the claim documents along with the invoice to the INSURER. This also follows an electronic route. iii) Scrutiny of Claim Docume nts The INSURER shall scrutinize the claim documents at the initial stage regarding the medical and eligibility aspect. Deficiency of any documents, if any, shall be communicated to the Network hospital within 7 working days. A reminder for the same will again be forwarded to the Network hospital once every 3 days of first intimation of the deficient documents are not received or are partially received. iv) Claim Control Number The INSURER will settle all eligible claims and pay the sum to the Network hospital within seven working days of receipt of the claim. A separate Claim Control Number is to be provided by insurer for every claim made by Network hospital. v) Payment of Claims and Claim Turn Around Time The INSURER will settle all eligible claims and pay the sum to the Provider within seven working days of receipt of the claim. vi) Repudiation of claims The INSURER on repudiation of the claim not covered under the policy, shall mention the reasons for repudiation on writing and online to the Network hospital. The INSURER shall also intimate the same to Rajiv Gandhi Jeevandayee Arogya Yojana Society online. vii) Right of Appeal and reopening of claim Network Hospital shall have a right of appeal to approach the Insurer if the Provider feels that the claim is payable. If Network Hospital is not agreed with the Insurers decision in this regard, can appeal to the Central Committee and the decision of the Central Committee will be final and binding on the INSURER and Network Hospital. This right of appeal will be mentioned by the INSURER in every repudiation advice as mentioned in above. The Central Committee can re-open the claim if proper and relevant documents as required are submitted. viii) Review of paid claims The Central committee will have the right to reopen a settled claim and to direct the Insurer to settle for an appropriate amount within a period of 3 months of payment of the claim. The Insurer further agrees to provide access to the Central Committee their records for this purpose. All the claims settled by the insurer to the network hospitals based on the bills received from the hospitals in conformity with the package rate arrived at and also based on the pre-authorization given by the reopening by the Insurance company will be reckoned as final and will not be subject to any reopening by any authority except the Central Committee for grievances. ix) Claim float and Bank Account The Insurer will have a separate Bank account to pay the Network hospital making a valid claim and all payments will be electronically cleared. Detailed reports will be
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electronically cleared. Detailed reports will be made available online on a real-times basis. x) Co-Ordination Committee A committee shall be constituted under the chairmanship of Chief Executive officer Rajiv Gandhi Jeevandayee Arogya Yojana Society including representative of Insurer and Network Hospital (nominated by Rajiv Gandhi Jeevandayee Society) to review smooth running and functioning of the identified activities. 31. RESPONSE TIME: Authorization will be decided within12 Working Hours and the Insurer shall do the settling of claims within 7 working days after receipt of documents. In case of life threatening emergencies, the preauthorization should be given immediately. To facilitate this, the e preauthorization would carry a sign of EM to seek priority attention of authorizers. Insurers response to the Rajiv Gandhi Jeevandayee Scheme will be immediate through: i. 24 hour call centre ii. Toll free line, exclusively for this Scheme. iii. Aarogyamithras in Rajiv Gandhi Jeevandayee Help Desks / Rajiv Gandhi Jeevandayee Assistance Counters iv. District Coordinators/ Regional Coordinators who are nominated exclusively for this purpose. 32. INSURER REPRESENTATIONS, WARRANTIES AND RESPONSIBILITIES a. Powe r, Capacity and Authority It has full power, capacity and authority to execute, deliver and perform this Agreement and it has taken all necessary action (corporate , statutory or otherwise), to execute, deliver, perform and authorize the execution, delivery and per formance of this Agreement and that it is fully empowered to enter into execute this Agreement, as well as perform all is obligations hereunder. b. Compliance with Memorandum and Articles Neither the making of this Agreement, nor compliance with its will be in conflict with or result in the breach of or constitute a default or require any consent under. I. Any provision of any agreement or other instrument to which such party is a party or by which it is bound; II. Any judgment, injunction, order, decree or award which is binding upon such party: and / or III. Such partys the Memorandum and/ or Articles of Association. c. Compliance with Laws It has complied with all applicable Laws including but not limited to the Insurance Regulatory and Development Authority Regulation. d. Risk Bearing Society as the buyer of insurance selected sold insurer i.e. xx Ltd as 100% risk bearer or carrier and no other insurer is allowed to participate in this direct insurance arrangement. e. Insurance License Throughout the term of this Agreement, the Insurer shall continue to be an Insurer under Law and licensed under IRDA regulations to carry on the activities contemplated herein f. Capability of Se rvice It is capable of servicing all the products and policies and offered and also have sufficient infrastructure, trained manpower and resources to carry out the activities for servicing these products and policies. g. Updating the list of Network Provider
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The empanelment of Network Providers will be a continuous process and the Ins urer will abide by the instructions of Rajiv Gandhi Jeevandayee Arogya Yojana Society in this regard. h. Disclose INSURER- Network Provide r agreement The INSURER agrees that it shall disclose to the society all agreements entered into by the INSURER with any Network Provider i. Steering Committee The INSURER shall have interrelated arrangements for common activities like empanelment of hospitals, planning for camps etc. Under the scheme with the society and other Insurers. A Steering Committee under the chairmanship of the CEO of Rajiv Gandhi Jeevandayee Arogya Yojana Society will oversee these arrangements. j. Code of conduct Abide by the code of conduct prescribed by the IRDA or any other governmental body from time to time. k. Discounts and Rebates Disclose and pass on to the Government/ Rajiv Gandhi Jeevandayee Arogya Yojana Society the benefit of any discount or rebates provided by the Network provider to the INSURER. l. Indemnity: The Insurer agrees to defend, indemnify and hold harmless the Insured, its employees, representatives and agents against all claims, demands, judgments, liabilities, damages, costs, expenses, proceedings or prosecutions arising from or relating to breach of any of the aforesaid representations, warranties, covenants and responsibilities. RUN-OFF PERIOD A Run Off period of one month will be allowed after the expiry of the policy period i.e. till the midnight of 1 November 2012 for 8 districts Phase-I. This means that pre-authorizations can be done till the end of policy period and surgeries for such pre-authorizations can be done up to one month after the expiry of policy period and such claim will be honored by the Insurance Company. 33. JURISDICTION: Any dispute arising out of this MOU shall be subject to the jurisdictio n of State of Maharashtra and Mumbai. 34. NON PERFORMANCE: Failure to perform and abide with the terms will attract the following in the event of termination: i) The Insurer will pay back to Rajiv Gandhi Jeevandayee Arogya Yojana Society within one week the unutilized amount of premium after settlement plus service tax ii) In addition to above, the Insurer will pay the total package amount for all the cases for which preauthorization has been given, but not claimed. iii) In addition to above, the Insurer shall pay interests at the rate of 12% per annum on the amount refundable as determined by clauses 18(i) and (ii) above for the period extending from the date of premium paid till the date of date receipt of refund. 35. INFORMATION FLOW: The Insurer will ensure that the information flow takes place on a real- time basis. The Insurer will use a state of the art dedicated Internet based network for this purpose. 36. RENEWAL: The policy may be renewed under the mutual consent of both the parties. The premium for renewal shall be agreed upon prior to the expiry of the existing policy. 37. THE PRECEDENCE OF MOU: The MOU has precedence over statements.
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38. MODIFICATION OF MOU: The MOU may be modified as and when the need arises in mutual agreement between Rajiv Gandhi Jeevandayee Arogya Yojana Society and Insurer. 39. MONITORING MECHANISM: Regular review meetings on the performance/ administration of the Scheme would be held between the Government of Maharashtra / Rajiv Gandhi Jeevandayee Arogya Yojana Society and the Insurer at the Insurer at the District level and at the State Level. The composition of the monitoring committees shall be as follows: District level: Chairman: District Collector Co-chairman: Chief Executive Officer Zillah Parishad. Membe rs: 1. District Health Officer. 2. District Supply Officer. 3. District Coordinator of Insurer. 4. Civil Surgeon Member Secretary For Mumbai and suburban Mumbai Chairman: Commissioner, BMC Co-chairman: Additional. Commissioner Health BMC. Membe rs: 1. District Collector 2. DMER, BMC or Dean of KEM hospital 3. Dean Grant Medical College Mumbai 4. Rationing Controller, Mumbai 5. District Coordinator of Insurer 6. Executive Health Officer BMC - Member Secretary State Level: Chairman: Additional Chief Secretary Public Health and Family Welfare Membe rs: 1. Director of Health Services 2. Director Medical Education and Research. 3. Dy. Commissioner Health BMC 3. Project Manager of the Insurer. 4. Member of the Rajiv Gandhi Jeevandayee Society 5. Technical Committee member nominated by Rajiv Gandhi Jeevandayee Society. 6. CEO, Rajiv Gandhi Jeevandayee Arogya Yojana Society Member Secretary. The Chairmen of the above committees may invite any non- official member in the project districts for the meetings. Periodical meetings will be organized at both district and State level. The agenda and issues to be discussed would be mutually decided in advance. The minutes of the meeting at the district and state level will be drawn and a copy will be forwarded to Rajiv Gandhi Jeevandayee Society. The Insurer shall also put in place a mechanism of their own to monitor the scheme on a real times basis. Detailed reports on the progress of the scheme and issues if any emerging out of such meetings shall be submitted to Government of Maharashtra / Rajiv Gandhi Jeevandayee Society. 40. GRIEVANCE MECHANISM: A District level Grievance redressal Committee: Grievance redressal Committee chaired by District Collector with following members will form the grievance redressal cell at the district level. The decision by the committee is binding except when an appeal to the central committee at the state level is preferred.
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Members of the Committee: 1. District coordinator of Insurer. 2. District Health Officer 3. Member from the Technical Committee (Nominated b y Rajiv Gandhi Jeevandayee Society) 4. Representative from the Insurer. 5. Civil Surgeon cum District Coordinator of the society Member Secretary. For Mumbai and suburban Mumbai Chairman: Commissioner, BMC Co-chairman: Additional. Commissioner Health BMC. Membe rs: 1. District Collector 2. DMER, BMC or Dean of KEM hospital 3. Dean Grant Medical College Mumbai 4. Rationing Controller, Mumbai 5. District Coordinator of Insurer 6. Executive health Officer BMC - Member Secretary B State Grievance redressal Committee: Committee Chaired by Chief Executive Officer of Rajiv Gandhi Jeevandayee Arogya Yojana Society will entertain all the appeals and grievances at the state level. The decision taken by the committee will be final and binding on the both parties. The committee may call the concerned Network Hospital against whom such grievance is reported. Members of the Committee: 1. Representative of the Rajiv Gandhi Jeevandayee Society 2. Technical Committee Member 3. Representative from the Insurance firm C. A tollfree number will be made available at Mumbai where any complaint can be registered. The Insurer will keep track of the complaints and report on the action taken to the Central Committee. The beneficiary families can also send e-mail / fax /letter to CEO of Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Zonal Office of the Insurer. The details of tollfree Numbers/ addresses will be available with PHCs and other Govt. hospitals. A separate set-up under the supervision of Executive Director of the Insurer at the Corporate Office will be setup to deal with the grievances. 41. TERMS & TERMINATION: 1. This Agreement shall take effect on the date of signature hereof by both Parties, and shall remain in force till the end of the policy period and the run off period subject to a right to Rajiv Gandhi Jeevandayee Arogya Yojana Society to terminate the Agreement, on a review of the performance of the INSURER before the same period. Rajiv Gandhi Jeevandayee Arogya Yojana Society will review the performance of the INSURER based o n factors including but not limited to: The facilities set up arrangements made by the INSURER toward servicing the beneficiary families. The extent of Network Hospital; The quality of service provided; The beneficiary families satisfaction reports received; Withholding of any information as sought by Rajiv Gandhi Jeevandayee Arogya Yojana Society at the Selection and implementation stage of the scheme; and Such other factors as the Rajiv Gandhi Jeevandayee Arogya Yojana Society/Government deems fit. 2. This Agreement may be terminated:
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By Rajiv Gandhi Jeevandayee Arogya Yojana Society before the period mentioned above as provided under clause 41 (1) b) By both parties by mutual consent; or c) Provided it gives the other party at least 60 days prior written notice; or In case of termination as given above: i) The Insurer will pay back to Rajiv Gandhi Jeevandayee Arogya Yojana Society within one week the unutilized amount of premium after settlement plus service tax ii) In addition to above, the Insurer will pay the total package amount for all the cases for which preauthorization has been given, but not claimed. iii) In addition to above, the Insurer shall pay interests at the rate of 12% per annum on the amount refundable as determined by clauses above for the period extending from the date of premium paid till the date of date receipt of refund. iv) Rajiv Gandhi Jeevandayee Arogya Yojana Society reserves the right to re-allot the policy to other insurer as it deems fit for the rest of the period in the event of termination and the Insurer shall not have any claims to it. v) Performance security will be forefeited. 42. FORCE MAJEURE: Neither party shall be in breach of any of its performance is prevented, physically hindered or by an act, event or circumstance (whet her of the kind described herein which is not reasonably within the control of such party (Force Majeure Event). In the event that any Force Majeure Event continues for a period of 4 (four) weeks without interruption, the Party affected by such Force Maje ure Event shall be entitled to terminate this agreement by giving notice to the other party, pursuant to, and in accordance with the provisions of clause provided it gives the other party at least 60 days prior written notice. 43. ASSIGNMENT:
1. 2. Neither party shall be entitled to assign its rights and/or obligations under this Agreement. Subject to the foregoing, this Agreement shall be fully binding upon Insurer to the benefit of and be enforceable by the parties hereto and the respective successors and permitted assigns.
a)
44. ENTIRE AGREEMENT: This Agreement entered into between Rajiv Gandhi Jeevandayee Arogya Yojana Society and the INSURER represents the entire agreement between the parties. 45. RELATIONSHIP:
The Parties to this Agreement are independent contractors. Neither Party is an agent, representative or partner of the other Party. Neither party shall have any right, power or authority to enter into any agreement or memorandum of understanding for or on behalf of, or incur any obligation or liability of, or to otherwise bind, the other party. This Agreement shall not be interpreted or construed to create an association, agency, joint venture, collaboration or partnership to such relationship upon either party .
46. SEVERABILITY: If any provision of this Agreement is invalid, unenforceable or prohibited by law, this Agreement shall be considered divisible as to such provision shall be inoperative and of the like effect as though such provision was not included herein: 47. NOTICES; Any notice given under or in connection with this Agreement shall be in writing and in the English language. Notices may be given delivered to the address of the addressee as set out below (in which case the notice shall be deemed to be served at the time of delivery) by courier services or by fax (in which case the original shall be sent by courier services).
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Name of the Insurer: ----------------------------------------. Attn: ------------------------------------. E-Mai : ----------------------------------. Fax: ------------------------. 48. GOVERNING LAW: The validity, performance, construction and effect of this Agreement shall be governed by the laws of the Republic of India. Any resolution of any disputes arising from or in connection with this Agreement, including a breach thereof, shall also be governed by the laws of the Republic of India. 49. DISPUTE RESOLUTION: 1. If any dispute arises between the parties hereto during the subsistence of this Agreement of thereafter, in connection with the validity Interpretatio n implementation or alleged breach of any provision of this Agreement, the parties shall refer such dispute to their respective chairmen/CEOs for resolution. In the event that the chairmen/CEOs are unable to resolve the dispute within 30 days of it being referred to them, then either Party may refer the dispute for resolution to a sole arbitrator who will be Additional Chief Secretary / Principal Secretary Public Health and Family Welfare Department Government of Maharashtra, or, in the event that the parties are unable to agree on the person to act as the sole arbitrator within 30 days after any party has claimed for an arbitrators in written form, by three arbitrators, one to be appointed by each party with power to the two arbitrators so appointed, to appoint a third arbitrator. 2. The law governing the arbitration shall be the Arbitration and Conciliation Act, 1996 as amended or re-enacted from time to time. 3. The proceedings of arbitration shall be conducted in the English language. 4. The arbitration shall be held in Mumbai, India (please refer 5 below). This deed is executed in two originals, both of which are operative instruments held by both the parties. For the Government / Rajiv Gandhi For Insurance Company Jeevandayee Society Chief Executive Officer Chairman Managing Director Witnesses: 1._______________________ 2. ________________________
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APPENDIX - I GENERAL GUIDELINES ON THE PACKAGES. 1. The package includes Consultation, medicines, diagnostics, specialist services Implants, grafts, prosthetics Food to patient Cost of transportation Hospital Charges, etc. In other words the packages should cover the entire cost of treatment of the patient from date of reporting, any complications while in hospital to discharge from hospital and 10 days after discharge, making the transaction truly cashless to the patient. The postoperative hospital stay in all surgical procedures shall be up to 10 days except in case of day care procedures, Medical interventions and chemotherapy for cancers. Civil & criminal claims arising out of medical negligence while treating beneficiary will be responsibility of network hospital & will be enforced under prevailing legal framework . 2. Hospital shall conduct all diagnostic tests as per standard protocols free of cost. 3. Hospital shall provide 10 days post discharge free follow up consultation, medicines and diagnostics to the patient within package. However, the extended follow up services are entitled for service elements shown in Appendix 1 b of Part IV. 4. Hospital shall provide reasonably good food to the patient, and shall make alternate arrangement for food wherever in-house pantry is not available. The hospital shall not give money as an alternative to food. 5.Hospital shall pay return fare for patient from hospital to place of residence of patient at ST fare. In instance of death, carriage of dead body from network hospital to village/town of the beneficiary would also be built in this package. 6.Hospital shall procure compatible blood for the surgeries. The hospital shall provide blood from their own blood bank if required. In case of non-availability the hospital shall procure from other blood banks, Red Cross, voluntary organizations, etc. 7. Hospital shall make all out efforts to apply and get the accreditation from NABH as soon as possible. 8.The general guidelines published by Rajiv Gandhi Jeevandayee Arogya Yojana Society separately from time to time shall be followed while implementing the packages. SPECIAL NOTES ON PACKAGES 1. Renal package: AV fistula and pre-transplant hemodialysis are approved along with ` surgery only and not separately. Hospital shall provide post-transplant immunosuppressive therapy for one year. 2. Cancer package: Chemotherapy and radiotherapy should be administered only by professionals trained in respective therapies (i.e. Medical Oncologists and Radiation Oncologists) and well versed with dealing with the side-effects the treatment can cause. Hospital should have qualified and registered oncologist, oncosurgeon and Radiotherapist. Tumour board comprising of qualified and registered oncologist, oncosurgeon and Radiotherapist will decide comprehensive treatment plan of patient. If hospital has no Radiotherapy equipment and Radiotherapist it should have tie up with nearest Radiotherapy center. Hospital should have qualified and registered oncologist, oncosurgeon and Radiotherapist. Tumour board comprising of qualified and registered oncologist, oncosurgeon and Radiotherapist will decide comprehensive treatment plan of patient. If hospital has no Radiotherapy equipment and Radiotherapist it should have tie up with nearest Radiotherapy center.
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Patients with hematological malignancies (leukemia, lymphomas, multiple myeloma) and pediatric malignancies (Any patient < 14 years of age) should be treated by qualified medical oncologists only. The advanced radiotherapy packages shall be utilized only for the cases and diseases which do not respond to conventional radiotherapy package. Each cycle cost includes Cost of chemotherapy drugs Hospital charges All infusional chemotherapy cancer cases must be treated as inpatients only. Doctors fees Supportive care medications (i.e. i.v. fluids, steroids, H2 blockers, anti-emetics) All investigations An average of Rs. 2000 to Rs. 5000/- has been added to the above cost, to cover for treatment of complications. Tumors not included in this list, if have a chemotherapy regimen that is proven to be curative, or provide long term improvements in overall survival will be reviewed on a case by case basis by the technical committee of the Society. 3. Polytrauma package: Components of Polytrauma: The components of polytrauma based on the system involved are: 1.Orthopedic trauma, 2. Neuro-Surgical Trauma, 3. Chest Injuries and 4.Abdominal Injuries. The above components may be treated separately or combined as the case warrants. For providing insurance coverage to polytrauma cases requiring Hospitalization and / or Surgery for Health card holders, management of each of the above can be classified as given below: Orthopedic trauma 1. Surgical Corrections Neuro-Surgical Trauma 1. Conservative 2. Surgical Treatment Chest Injuries 1. Conservative 2. Surgical treatment Abdominal Injuries 1. Conservative 2. Surgical treatment I. All cases, which require conservative management with a minimum of one-week hospitalization with evidence of (Imageology based) seriousness of injury to warrant admission, only need to be covered to avoid misuse o f the scheme for minor / trivial cases. II. In case of Neurosurgical trauma, admission is based on both Imageology evidence and clinical evidence. III. All surgeries related to polytrauma are covered irrespective of hospitalization period. IV. Initial evaluation of all trauma patients has to be free of cost. 4. Prostheses: i) Cost of prosthesis is inclusive of foot and shoe, wherever required. ii) Prosthesis must have been manufactured with the materials with BIS (Bureau of Indian Standards) certification. iii) All prosthesis shall be functional in nature. iv) Manufacturer shall give minimum of 3 years replacement Guarantee. v) Manufacturer shall provide free replacement of leather parts / straps, etc. during this period apart from replacement guarantee.
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DETAILED LIST OF SPECIFIED SURGERIES AND THERAPIES

972 procedures Sr No Specialty SYSTEM
Indicativ e Rate &
APPENDIX: 1A
General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck Thyroid Non Malignant General surgery Head and Neck Thyroid Non Malignant General surgery Head and Neck Thyroid Non Malignant
2 3
4 5
6 7 8 9
10
11 12 13
14 15 16
Brach ial Cyst Excision Inv - Clinical Photograph Post procedure evidence of Clin ical photograph, Biopsy Cerv ical Rib excision Inv - Color Doppler , XRA Y Post procedure evidence of X-Ray/Color doppler Removal o f Sub mandibular Salivary gland Inv Clin ical Photograph , FNA C Post procedure evidence of Clin ical photograph, Biopsy Parotid Duct Repair Inv - Silography Post procedure evidence of Silography Branchial Sinus Excision Inv -Clinical Photograph Post procedure evidence of Clin ical photograph, Biopsy Hemimandibulecto my Inv - X-Ray Post procedure evidence of X-Ray Segmental Mandible Excision Inv - X-Ray Post procedure evidence of X-Ray Carotid Body-tumours Excision Inv - Clinical Photograph , U S Neck Post procedure evidence of Clin ical Photograph, Biopsy Partial g lossectomy Inv - Clin ical Photograph, Biopsy Post procedure evidence of Clinical Photograph, Biopsy Cystic Hygro ma Excision-Extensive Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph, Biopsy Abbe Operation Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph Vermilionectomy Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph Wedge Excision& Vermilionectomy Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph, Biopsy Wedge Excision Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph,Biopsy Cystic Hygro ma Excision-Major Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph, Biopsy Hemithyroidectomy Inv - FNAC , T F T , USG Post procedure evidence of Clin ical Photograph, Biopsy Isthmectomy Inv - FNAC , T F T , USG Post procedure evidence of Clin ical Photograph, Biopsy Partial Thyroidecto my Inv - FNAC , T F T , USG Post procedure evidence of Clin ical Photograph, Biopsy
Upper ceiling (Rs.) 20000
15000 10000
20000 20000
25000 25000 30000 15000
20000
15000 15000 20000
15000 20000 20000
17
20000
18
20000
~ 67 ~

Indicativ e Rate &
19
20
21
22
General surgery Head and Neck Thyroid Non Malignant General surgery Head and Neck Thyroid Non Malignant General surgery Head and Neck Thyroid Non Malignant General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck General surgery Head and Neck
Resection Enucleation Inv - FNAC , T F T , USG Post procedure evidence of Clin ical Photograph, Biopsy Subtotal Thyroidectomy Inv - FNA C , T F T , USG Post procedure evidence of Clin ical Photograph, Biopsy Total Thyroidectomy Inv - FNA C , T F T , USG Post procedure evidence of Clin ical Photograph, Biopsy Cystic Hygro ma Excision-Minor Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph, Biopsy Excision of Lingual Thyro id Inv - Clinical Photograph , Isotope Scan Post procedure evidence of Clin ical Photograph, Biopsy Parathyroidectomy Inv - USG Post procedure evidence of Clin ical Photograph, Biopsy Excision of Thyroglossal Cyst Fistula Inv Clin ical Photograph , Radionucleide Scan Post procedure evidence of Clin ical Photograph, Biopsy Simp le Mastectomy(NM) Inv -Mammography Post procedure evidence of Clin ical Photograph, Biopsy Ep igastric Hern ia without Mesh Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph Ep igastric Hern ia with Mesh Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph Femoral Hernia Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph Hiatus Hern ia Repair Abdominal Inv -U S Abdomen , UGI Endoscopy Post procedure evidence of Clin ical Photograph Rare Hernias (Sp igalion,obuturator,sciatic) Inv Clin ical Photograph , USG Post procedure evidence of Clin ical Photograph Umbilical Hernia without mesh Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph Umbilical Hernia with mesh Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph Ventral and Scar Hernia without mesh Inv Clin ical Photograph , USG Post procedure evidence of Clin ical Photograph Ventral and Scar Hernia with mesh Inv - Clin ical Photograph , USG Post procedure evidence of Clin ical Photograph Lap. Appendectomy Inv - USG Post procedure evidence of Video, Biopsy, Clin ical Photo
20000
20000
10000
23 24 25
25000 30000 15000
26 27
General surgery Breast General surgery Abdomen Hernia General surgery Abdomen Hern ia General surgery Abdomen Hern ia General surgery Abdomen Hern ia General surgery Abdomen Hern ia General surgery Abdomen Hern ia General surgery Abdomen Hern ia General surgery Abdomen Hern ia General surgery Abdomen Hern ia General surgery Abdomen
20000 15000
28
30000
29 30
15000 35000
31
20000
32 33
15000 25000
34
20000
35 36
30000 22000
~ 68 ~

Indicativ e Rate &
37
General surgery Abdomen General surgery Abdomen Stomach, Duodenum, Jejunum General surgery Abdomen Stomach, Duodenum, Jejunum General surgery Abdomen Stomach, Duodenum, Jejunum General surgery Abdomen Stomach, Duodenum, Jejunum General surgery Abdomen Stomach, Duodenum, Jejunum General surgery Abdomen Stomach, Duodenum, Jejunum General surgery Abdomen Stomach, Duodenum, Jejunum General surgery Abdomen Stomach, Duodenum, Jejunum General surgery Abdomen Stomach, Duodenum, Jejunum General surgery Abdomen Stomach, Duodenum, Jejunum General surgery Abdomen Small Intestine General surgery Abdomen Small Intestine General surgery Abdomen Small Intestine General surgery Abdomen Small Intestine General surgery Abdomen Small Intestine General surgery Abdomen Small Intestine
38 39
Appendicular perfo ration Inv - USG Post procedure evidence of Clin ical photograph, Biopsy Highly Select ive Vagotomised Inv - Endoscopy Post procedure evidence of Clin ical photograph Duodenal perforation Inv - CT-Abdomen , USG , X-Ray Post procedure evidence of Clin ical photograph Selective Vagotomy Drainage Inv - Endoscopy Post procedure evidence of Clin ical photograph Vagotomy Pylo roplasty Inv - Endoscopy Post procedure evidence of Clin ical photograph Gastrojejunostomy & Vagotomy Inv - EndoscopyVideo Photo Post procedure evidence of Clinical photograph Operation for bleeding peptic ulcer Inv Endoscopy Post procedure evidence of Clinical photograph Partial/subtotal Gastrectomy for u lcer Inv Endoscopy Post procedure evidence of Clin ical photograph Pyloro myotomy Inv - Endoscopy Post procedure evidence of Clin ical photograph Gastrostomy Inv - Biopsy , CT , Endoscopy , USG Post procedure evidence of Clin ical photograph Gastrostomy Closure Inv -Clin ical Photograph Post procedure evidence of Clin ical photograph Intussusception Inv - Endoscopy , USG , X-Ray ABD Post procedure evidence of Clinical photograph/Biopsy Operation for Acute intestinal obstruction Inv Biopsy , Endoscopy , USG , X-Ray ABD Post procedure evidence of Clin ical photograph/Biopsy Operation for Acute intestinal perforation Inv Biopsy , CXR , Endoscopy , USG , X-Ray A BD Post procedure evidence of Clin ical photograph/Biopsy Operation for Haemo rrhage of the small intestine Inv - CT W ith Contrast , Endoscopy Post procedure evidence of Clin ical photograph/Biopsy Operations for Recurrent intestinal obstruction (Noble p licat ion other) Inv - CT-Contrast Post procedure evidence of Clin ical photograph/Biopsy Resection & Anastomosis of small intestine Inv CT , X-Ray ABD Post procedure evidence of Clin ical photograph/Biopsy
25000 20000
40
40000
41 42
30000 30000
43
40000
44 45
40000 20000
46
20000
47 48
20000 30000
49
30000
50
30000
51
40000
52
35000
53
35000
~ 69 ~

Indicativ e Rate &
54
55 56
57
58 59
60
61 62
63
64 65
General surgery Abdomen Small Intestine General surgery Abdomen Small Intestine General surgery Abdomen Large Intestine General surgery Abdomen Large Intestine General surgery Abdomen Large Intestine General surgery Abdomen Large Intestine General surgery Abdomen Large Intestine General surgery Abdomen Large Intestine General surgery Abdomen Large Intestine General surgery Abdomen Large Intestine General surgery Abdomen Rectu m and anus General surgery Abdomen Rectu m and anus General surgery Liver General surgery Liver General surgery Gall bladder General surgery Gall bladder General surgery Gall bladder General surgery Gall bladder General surgery Gall bladder
Ileostomy Inv - Biopsy , Endoscopy , USG Post procedure evidence of Clin ical photograph Ileostomy Closure Inv - Clinical Photograph Post procedure evidence of Clin ical photography Mal-rotation & Volvu lus of the midgut Inv - CT , X-Ray ABD Post procedure evidence of XRay/Clinical photograph Operation for Vo lvulus of large bowel Inv - CTContrast , X-Ray Abdomen Post procedure evidence of X-Ray/ Clinical photograph Operation of the Duplication of the intestines Inv CT-Contrast Post procedure evidence of Clinical photograph Left Hemi Co lectomy Inv - Bariu m , CT , Endoscopy , USG Post procedure evidence of Clin ical photograph/Biopsy Right Hemi colecto my Inv - Bariu m , CT , Endoscopy , USG Post procedure evidence of Clin ical photograph/Biopsy Total Co lectomy Inv - Bariu m , CT , Endoscopy , USG Post procedure evidence of Clin ical photograph/Biopsy Colostomy Inv - Bariu m , CT , Endoscopy , USG Post procedure evidence of Clin ical photograph Colostomy Closure Inv - Clinical Photograph Post procedure evidence of Clin ical photograph Pull through abdominal resection Inv - Clinical Photograph Post procedure evidence of Clin ical photograph Anterior Resection Inv - Biopsy , Clin ical Photograph , Colonoscopy Post procedure evidence of Clin ical photograph/Biopsy Operation for Hydatid cyst of liver Inv - CT , USG Post procedure evidence of USG Portocaval Anastomosis Inv - MRI , UGI Endoscopy , USG Post procedure evidence of USG,Endoscopy Cholecystectomy Inv - CT , LFT , USG Post procedure evidence of Clin ical photograph,USG Lap.Cholecystectomy Inv - CT , LFT , USG Post procedure evidence of Clin ical photograph,USG, Video Cholecystectomy & Exp loration CBD Inv - CT , LFT , USG Post procedure evidence of Clin ical photograph,USG, T-Tube, Cholangiogram Lap Cholecystostomy with Explorat ion CBD Inv CT , LFT , USG Post procedure evidence of Clin ical photograph,USG Cystojejunostomy Inv - CT , LFT , USG Post procedure evidence of Clin ical photograph,USG
20000 35000
40000
40000 30000
30000
40000 20000
20000
30000 50000
66 67
30000 80000
68 69 70
20000 25000 25000
71
30000
72
40000
~ 70 ~

Indicativ e Rate &
73 74
General surgery Gall bladder General surgery Gall bladder General surgery Adrenals General surgery Adrenals General surgery Spleen General surgery Spleen General surgery Spleen ENT surgery Ear ENT surgery Ear ENT surgery Ear ENT surgery Throat ENT surgery Throat
Cystogastrostomy Inv - CT , LFT , USG Post procedure evidence of Clin ical photograph,USG Repair of CBD Inv - CT , LFT , USG Post procedure evidence of Clin ical photograph,USG, T-Tube, Cholangiogram Operation of Adrenal g lands, bilateral fo r tu mour Inv - Biochemical Investigations , CT , USG Post procedure evidence of USG,Biopsy Operation on Adrenal glands unilateral for tu mour Inv - Biochemical Investigations , CT , USG Post procedure evidence of USG,Biopsy Splenectomy fo r Hypersplenism Inv - CT , Peripheral Smear , USG Post procedure evidence of USG Splenorenal Anastomosis Inv - MRI , UGI Endoscopy , USG Post procedure evidence of USG,Endoscopy Warren shunt Inv - MRI , UGI Endoscopy , USG Post procedure evidence of USG,Endoscopy Labyrinthectomy Inv - CT-Scan PTI , IA Post procedure evidence of Clin ical photograph Facial Nerve Deco mpression Inv - CT-Scan Post procedure evidence of Clin ical photograph Temporal Bone Excision Inv - CT-Scan MRI Scan Post procedure evidence of Clin ical photograph Microlaryngeal Surgery Inv - Nasal Endoscopy Post procedure evidence of Clin ical photograph Phono Surgery for Vocal cord paralysis Inv - CTScan MRI Scan Post procedure evidence of Clin ical photograph Laryngo Fissurectomy Inv - CT-Scan Post procedure evidence of Clin ical photograph Excision of Tu mours in Pharyn x Inv - FNA C Post procedure evidence of Clin ical photograph, Biopsy Parapharyngeal tumour Excision Inv - CT-Scan MRI Scan , FNAC Post procedure evidence of Clin ical photograph,Biopsy Adenoidectomy - Gro met insertion Inv Impedance Audiometry , X-Ray Nasopharynx Post procedure evidence of Clin ical photograph Uvulo-palato Pharyngoplasty Inv Polysomnography Post procedure evidence of Clin ical photograph Endoscopic Sinus Surgery Inv - CT PNS , DNE Photo graph Post procedure evidence of Endoscopy photo Mastoidectomy Inv - CT Temporal Bone , PTA Post procedure evidence of X-Ray mastoids Tympanoplasty Inv - PTA , X-Ray Mastoids Post procedure evidence of PTA,Per OP photo.
Upper ceiling (Rs.) 40000 25000
75
40000
76
25000
77 78
35000 60000
79 80 81 82 83 84
60000 20000 20000 50000 12000 25000
85 86
ENT surgery Throat ENT surgery Throat
20000 20000
87
ENT surgery Throat
20000
88 89
ENT surgery Throat ENT surgery Throat
10000 25000
90
ENT surgery Nose
15000
91 92
ENT surgery Nose ENT surgery Nose
15000 15000
~ 71 ~

Indicativ e Rate &
93
ENT surgery Nose
94
ENT surgery Nose
95 96 97
ENT surgery Nose ENT surgery Nose ENT
98 99 100 101 102 103 104
Ophthalmo logy Cornea Sclera Ophthalmo logy Cornea Sclera Ophthalmo logy Cornea Sclera Ophthalmo logy Cornea Sclera Ophthalmo logy Cornea Sclera Ophthalmo logy Cornea Sclera Ophthalmo logy Cornea Sclera Ophthalmo logy Vitreo Ophthalmo logy Vitreo Ophthalmo logy Vitreo
Stapedectomy + Veingraft Inv - CT Temporal Bone , Impedance Audiometry , PTA Post procedure evidence of Clin ical photo with piston+vein graft. Excision of benign tu mour nose Inv - CT PNS , DNE Post procedure evidence of Clin ical photograph Angiofibro ma nose Inv - CT PNS , DNE Post procedure evidence of Clin ical photograph Endoscopic DCR Inv - Clinical Photograph Post procedure evidence of Endoscopic photo Bronchoscopic foreign body removal Inv Relevant X-Ray Post procedure evidence of Clin ical photograph Therapeutic penetrating keratoplasty Inv - B Scan Post procedure evidence of Clin ical photograph Lamellar keratoplasty Inv - B Scan Post procedure evidence of Clin ical photograph Corneal patch graft Inv -Clin ical Photograph Post procedure evidence of Clin ical photograph Scleral patch graft Inv - Clin ical Photograph Post procedure evidence of Clin ical photograph Penetrating keratoplasty Inv - Clinical Photograph Post procedure evidence of Clin ical photograph Double Z plasty Inv - Clin ical Photograph Post procedure evidence of Clin ical photograph Amniotic memb rane graft Inv - Clinical Photograph Post procedure evidence of Clin ical photograph Vitrecto my Inv - B Scan Post procedure evidence of Clinical photograph Vitrecto my + Membrane peeling+ endolaser Inv B.Scan , Fundus Photograph Post procedure evidence of Fundus photograph Monthly Intravitreal Anti-VEGF for macular degeneration - per in jection (maximu m - 6) Inv B.Scan , Fundus Photograph Post procedure evidence of Fundus photo, Fundus fluorescence angiography and optical coherence tomography. Vitrecto my - Membrane peeling endolaser , Silicon oil or gas Inv - B.Scan , Fundus Photograph Post procedure evidence of Fundus photograph Scleral buckle for Ret inal detach ment Inv B.Scan , Fundus Photograph Post procedure evidence of Fundus photograph Photocoagulation for diabetic retinopathy per sitting Inv - B.Scan , Fundus Photograph Post procedure evidence of Fundus photograph Vitrecto my plus silicon oil or gas Inv - B.Scan , Fundus Photograph Post procedure evidence of Fundus photograph
15000
40000 20000 20000
15000 3000 4000 6000 15000 4000 7000
105 106
6000 25000
107
7000
108
Ophthalmo logy Vitreo Ophthalmo logy Retina Ophthalmo logy Retina Ophthalmo logy Vitreo
30000
109
15000
110
1500
111
20000
~ 72 ~

Indicativ e Rate &
112
Ophthalmo logy Vitreo Ophthalmo logy Orb it Ophthalmo logy Orb it Ophthalmo logy Orb it Ophthalmo logy Orb it
113 114 115 116
Removal Of Silicon Oil Or Gas Inv - B.Scan , Fundus Photograph Post procedure evidence of Fundus photograph Socket reconstruction Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph Dermis fat graft Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph Orbitoto my Inv - CT Scan Post procedure evidence of Clin ical Photograph Enuleation with orb ital imp lant Inv - CT Skull , Clin ical Photograph , Orb it Post procedure evidence of Clin ical Photograph Rectus muscle surgery single Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph Rectus muscle surgery Two/Three Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph Oblique muscle Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph Lid reconstruction surgery Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph Photocoagulation for Ret inopathy of prematurity Inv - Fundus Fluorescence Angiography , Fundus Photograph , Optical Coherence To mography Post procedure evidence of Clin ical Photograph showing procedure. Pediatric cataract surgery - Phacoemulsification IOL Inv - B.Scan , Fundus Photograph Post procedure evidence of Clin ical Photograph Glauco ma filtering surgery for paediatric Glauco ma Inv - USG Fundus Fluorescence Angiography , Fundus Photograph Post procedure evidence of Clin ical Photograph Caesarean Hysterectomy with Bladder Repair Inv - USG Post procedure evidence of Post op USG/ Photograph Rupture Uterus Inv - USG Post procedure evidence of USG Eclampsia with co mplication requiring ventilatory support Inv - ABG , APTT , CUE , Haematocrit , LFT , PT , Platelet Count , RFT , S.Fibrinogen Level Post procedure evidence of Clinical Photograph, Biochemical investigations Abruptioo placenta with coagulation defect - DIC. Inv - APTT , Heamatocrit , PT , Platelet Count , S.Fibrinogen Level , USG Post procedure evidence of Clin ical Photograph of retroplacental clots, USG LA VH Inv - USG Post procedure evidence of Post op USG,Biopsy,Video.
7000 9000 10000 20000
117 118
119
120 121
Ophthalmo logy Squint correction surgery Ophthalmo logy Squint correction surgery Ophthalmo logy Squint correction surgery Ophthalmo logy Lid surgery Pediatric Ophthalmic surgery
6000 12000
6000
15000 7500
122
Pediatric Ophthalmic surgery Pediatric Ophthalmic surgery
15000
123
15000
124
Obstetrics
30000
125 126
Obstetrics Obstetrics
25000 20000
127
Obstetrics
20000
128
Gynaecology
30000
~ 73 ~

Indicativ e Rate &
129
Gynaecology
130 131
Gynaecology Gynaecology
Vaginal Hysterectomy with pelvic floor repair Inv - Scan Post procedure evidence of Post op USG,Biopsy Vaginal Hysterectomy with Mesh repair Inv USG Post procedure evidence of Post op USG,Biopsy Cystocele ,Rectocele & Perineorraphy Inv - USG Post procedure evidence of Post op USG,Biopsy Pelvic floor Reconstruction with mesh Inv - USG Post procedure evidence of Post op USG,Biopsy Mc Indo-s repair fo r Vag inal Atresia Inv - Post procedure evidence of Post op USG,Biopsy Slings with mesh repair for prolapse Inv - USG Post procedure evidence of USG Vault prolapse abdominal repair Inv - Clinical Photograph , USG Post procedure evidence of USG Vault prolapse abdominal repair with mesh Inv Clin ical Photograph , USG Post procedure evidence of USG Laparoscopic Cystectomy Inv - USG Post procedure evidence of USG,Biopsy,Video. Laparoscopic Ectopic Resection Inv - USG Post procedure evidence of USG,Biopsy,Video. Laparoscopic ovarian drilling Inv - USG Post procedure evidence of USG,Biopsy,Video. Laparoscopic Myomectomy Inv - USG Post procedure evidence of USG,Biopsy,Video. Laparoscopic recanalisation Inv - USG Post procedure evidence of USG,Biopsy,Video. Laparoscopic Sling operations Inv - USG Post procedure evidence of USG,Biopsy,Video. Laparoscopic adhesolysis Inv - USG Post procedure evidence of USG,Biopsy,Video. Vaginal Hysterectomy Inv - Scan Post procedure evidence of Post op USG AND Biopsy Bone Grafting as exclusive procedure Inv - X-Ray Post procedure evidence of Post op X-Ray Excision or other Operations for Scaphoid Fractures Inv - X-Ray Post procedure evidence of Post op X-Ray Open Reduction & Internal Fixation of Fingers & Toes @Rs5000 each up to maximu m of Rs 15000 Inv - X-Ray Post procedure evidence of Post op X-Ray Reduction of Co mpound Fractures & External fixation Inv -X-Ray Post procedure evidence of Post op X-Ray ILIZA ROV Ring Fixator Application Inv - X-Ray Post procedure evidence of Clin ical photograph,XRay
25000 20000
132
Gynaecology
20000
133 134 135
Gynaecology Gynaecology Gynaecology
30000 40000 25000
136 137 138 139 140 141 142 143 144 145 146
Gynaecology Gynaecology Gynaecology Gynaecology Gynaecology Gynaecology Gynaecology Gynaecology Gynaecology Orthopedics Fracture Correct ion Surgeries Orthopedics Fracture Correct ion Surgeries Orthopedics Fracture Correct ion Surgeries
25000 20000 20000 15000 25000 20000 25000 25000 20000 20000 15000
147
15000
148 149
Orthopedics Fracture Correct ion Surgeries Orthopedics Fracture Correct ion Surgeries
15000 40000
~ 74 ~

Indicativ e Rate &
150
Orthopedics Fracture Correct ion Surgeries Orthopedics Orthopedics
151 152
CTEV Neglected . JESS Fixator Inv - Clinical Photograph Post procedure evidence of Clin ical photograph,X-Ray Open Reduction of Dislocations - Deep Inv - XRay Post procedure evidence of Post op X-Ray Amputations - Forequarter Inv - X-Ray Post procedure evidence of Clin ical photograph,X-Ray Amputations - Hind Quarter and Hemipelvectomy Inv - X-Ray Post procedure evidence of Clin ical photograph,X-Ray Arthrodesis of - Major Joints Inv - Flu id Analysis , X-Ray Post procedure evidence of Post op X-Ray Arthroscopy - Diagnostic Inv - M RI Post procedure evidence of Arthroscopy picture Arthroscopy . Operative Meniscectomy Inv - M RI Post procedure evidence of Arthroscopy picture Arthroscopy - ACL Repair Inv - MRI Post procedure evidence of Arthroscopy picture Avascular Necrosis of Femo ral Head (core decompression) Inv - MRI , X-Ray Post procedure evidence of Post op X-Ray Soft Tissue reconstruction Procedures for Joints/Osteotomy Inv - Clinical Photograph Post procedure evidence of Clin ical photograph,X-Ray Anterolateral Clearance for Tuberculosis Inv MRI Post procedure evidence of Post op X-Ray, Biopsy Costo Transversectomy Inv - MRI Post procedure evidence of Post op X-Ray Spinal Ostectomy and Internal Fixations Inv MRI Post procedure evidence of Post op X-Ray Nerve Repair with Graft ing Inv - Clinical Photograph Post procedure evidence of Clinical Photograph Neurolysis/Nerve Suture Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph Operations for Brachial Plexus & Cerv ical Rib Inv - M RI Post procedure evidence of Clinical Photograph,X-Ray Excision of Bone Tu mours . Deep with reconstruction with conventional prosthes is Inv MRI Post procedure evidence of Clin ical Photograph,X-Ray Surgery for Bleeding Ulcers Inv - Endoscopy Post procedure evidence of Endoscopy picture Surgery for Obscure GI Bleed Inv - Endoscopy Post procedure evidence of Endoscopy picture
30000 30000
153
Orthopedics
40000
154 155
156
157 158
Orthopedics Bone and Joint Surgery procedures Orthopedics Bone and Joint Surgery procedures Orthopedics Bone and Joint Surgery procedures Orthopedics Bone and Joint Surgery procedures Orthopedics Bone and Joint Surgery procedures Orthopedics Bone and Joint Surgery procedures Orthopedics spine Surgery Orthopedics Spine surgery Orthopedics Spine surgery Orthopedics Soft Tissue Surgery Orthopedics Soft Tissue Surgery Orthopedics Soft Tissue Surgery Orthopedics Bone tumours
30000 20000
25000
30000 15000
159
30000
160 161 162 163
50000 30000 40000 30000
164 165
25000 30000
166
40000
167
168
Surgical Gastroenterology Emergency Surgical Gastroenterology
40000
60000
~ 75 ~

Indicativ e Rate &
Upper ceiling (Rs.) Emergency
169
Surgical Gastroenterology Emergency Surgical Gastroenterology Liver Surgical Gastroenterology Liver Surgical Gastroenterology Liver Surgical Gastroenterology Pancreas Surgical Gastroenterology Pancreas Surgical Gastroenterology Pancreas Surgical Gastroenterology Pancreas Surgical Gastroenterology Pancreas Surgical Gastroenterology Oesophagus Surgical Gastroenterology Oesophagus Surgical Gastroenterology Oesophagus Surgical Gastroenterology Oesophagus Surgical Gastroenterology Oesophagus Surgical Gastroenterology Stomach Surgical Gastroenterology Stomach Surgical Gastroenterology Stomach
170 171
172
173 174
Diaphrag matic Hernia (Gortex Mesh Repair) Inv Ba.Study , CXR , Endoscopy , USG Post procedure evidence of Clin ical photograph, Biopsy Rt Hepatectomy Inv - CT , ERClinical Photograph , USG Post procedure evidence of Clin ical photograph, USG Lt Hepatectomy Inv - CT , ERClinical Photograph , USG Post procedure evidence of Clin ical photograph, USG Segmentectomy Inv - CT , ERClinical Photograph , USG Post procedure evidence of Clin ical photograph, USG Distal Pancreatectomy Inv - CT , ERCP Post procedure evidence of Clin ical photograph, USG Enucleation of cyst Inv - CT Post procedure evidence of Clin ical photograph, USG Whipples any type Inv - CT , ERCP Post procedure evidence of Clin ical photograph, USG Trip le bypass Inv - CT Post procedure evidence of Clin ical photograph, USG Other Bypasses Inv - CT Post procedure evidence of Clinical photograph, USG Colonic Pull up Inv - Biopsy , CT-Scan , Endoscopy Post procedure evidence of Clinical photograph, Biopsy Oesophagectomy Inv - Biopsy , CT-Scan , Endoscopy Post procedure evidence of Endoscopy picture, Biopsy Oesophago-Gastrectomy Inv - Biopsy , CT-Scan , Endoscopy Post procedure evidence of Endoscopy picture, Biopsy Lap Hellers myotomy Inv - Biopsy , CT-Scan , Endoscopy Post procedure evidence of Endoscopy picture, Biopsy Lap Fundoplicat ions Inv - Biopsy , CT-Scan , Endoscopy Post procedure evidence of Endoscopy picture, Biopsy Partial Gastrectomy Inv - Biopsy , EUS , USG Post procedure evidence of Clin ical photograph,Biopsy Total Gastrectomy Inv - Biopsy , CT-Scan , Endoscopy , USG Post procedure evidence of Clin ical photograph,Biopsy Truncal vagotomy + Gastro Jejunostomy Inv Biopsy , CT-Scan , Endoscopy , USG Post procedure evidence of Clin ical photograph,Biopsy
40000
75000 75000
50000
100000 75000
175
75000
176 177
25000 25000
178
30000
179 180
60000 75000
181
30000
182 183
45000 40000
184
40000
185
40000
~ 76 ~

Indicativ e Rate &
186
Surgical Gastroenterology Stomach Surgical Gastroenterology Stomach Surgical Gastroenterology Small Intestine Surgical Gastroenterology Small Intestine Surgical Gastroenterology Small Intestine Surgical Gastroenterology Large Intestine Surgical Gastroenterology Large Intestine Surgical Gastroenterology Large Intestine Surgical Gastroenterology Large Intestine Surgical Gastroenterology Large Intestine Surgical Gastroenterology Large Intestine Surgical Gastroenterology Large Intestine Surgical Gastroenterology Ulcerative colitis III stage procedure Surgical Gastroenterology Ulcerative colitis III stage procedure Surgical Gastroenterology Ulcerative colitis III stage procedure
187
188
189 190
191
192 193
194
195
196
197
198
199
Distal Gastrectomy for Gastric Outlet obstruction Inv - Biopsy , CT-Scan , Endoscopy , USG Post procedure evidence of Clin ical photograph,Biopsy Surgery for Corrosive inju ry Sto mach Inv Biopsy , CT-Scan , Endoscopy , USG Post procedure evidence of Clin ical photograph,Biopsy Vo lvulus Inv - CT-Scan , X-Ray ABD Post procedure evidence of Clin ical photograph,Biopsy Malrotation Inv - CT-Scan , X-Ray ABD Post procedure evidence of Clin ical photograph,Biopsy Lap Adhesiolysis Inv - CT-Scan , X-Ray ABD Post procedure evidence of Clinical photograph,Biopsy Right Hemicolecto my Inv - Biopsy , CT-Scan , Colonoscopy , Endoscopy Post procedure evidence of Clinical photograph,Biopsy Left Hemicolecto my Inv - Biopsy , CT-Scan , Colonoscopy , Endoscopy Post procedure evidence of Clinical photograph,Biopsy Extended Right Hemico lectomy Inv - Biopsy , CT-Scan , Co lonoscopy , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy Anterior Resection Inv - Biopsy , CT-Scan , Colonoscopy , Endoscopy Post procedure evidence of Clinical photograph,Biopsy Anterior Resection with Ileostomy Inv - Biopsy , CT-Scan , Co lonoscopy , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy Abdomino Perineal Resection(Non-Malignant) Inv - Biopsy , CT-Scan , Colonoscopy , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy Hart man.s Procedure with Colostomy Inv - Biopsy , CT-Scan , Colonoscopy , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy I Stage-Sub Total Co lectomy + Ileostomy Inv CT-Scan with Contrast , Colonoscopy , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy II Stage-J - Pouch Inv - Colonoscopy Post procedure evidence of Clin ical photograph,Biopsy III Stage-Ileostomy Closure Inv - Endoscopy Post procedure evidence of Clin ical photograph,Biopsy
50000
40000
40000 40000
30000
30000 35000
40000
50000
50000
45000
50000
30000
200
20000
~ 77 ~

Indicativ e Rate &
201
Surgical Gastroenterology Ulcerative colitis II stage procedure Surgical Gastroenterology Ulcerative colitis II stage procedure Surgical Gastroenterology Liver
I Stage- Sub Total Colecto my + Ileostomy + J Pouch Inv - CT-Scan with Contrast , Co lonoscopy , Endoscopy Post procedure evidence of Clinical photograph,Biopsy II Stage- Ileostomy Closure Inv - CT-Scan with Contrast , Colonoscopy , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy Hepato Cellular Carcino ma(Advanced) Radio Frequency Ablation Inv - Biopsy , CT-Scan , EUSDiagnostic Laparoscopy , Intra operative Ultrasound Post procedure evidence of Clin ical photograph/USG Haemangio ma SOL Liver Hepatectomy + Wedge Resection Inv - CT-Scan , Endoscopy , USG Post procedure evidence of Clin ical photograph/Biopsy/USG Hydatid cyst-Marsupilisation Inv - Biopsy , CTScan , USG Post procedure evidence of Clinical photograph/Biopsy/USG Cyst excision + Hepatic Jejunostomy Inv - CT , USG Post procedure evidence of Clinical photograph,Biopsy GB+ Calculi CBD Stones or Dilated CBD Inv CBD , ERClinical Photograph , USG Post procedure evidence of Clin ical photograph,Biopsy Hepatico Jejunostomy Inv - Biopsy , CT-Scan Post procedure evidence of Clinical photograph,Biopsy Choledochoduodenostomy Or Choledocho jejunostomy Inv - CT , USG Post procedure evidence of Clinical photograph,Biopsy Splenectomy Inv - CT , USG Post procedure evidence of Clinical photograph,USG Splenectomy + Devascularisation + Spleno Renal Shunt Inv - CT , USG Post procedure evidence of Clin ical photograph,Biopsy Spleenectomy for Space occupying lesion Inv CT , USG Post procedure evidence of Clinical photograph,USG Lap- Pancreatic Necrosectomy Inv - CT-Scan , ERCP , ERClinical Photograph , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy Lateral PancreaticoJejunostomy(Non- Malignant) Inv - CT-Scan , ERCP , ERClinical Photograph , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy Pancreatic Necrosectomy (open) Inv - CT-Scan , ERCP , ERClinical Photograph , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy
202
20000
203
60000
204
Surgical Gastroenterology Liver Surgical Gastroenterology Liver Surgical Gastroenterology Gall Bladder Surgical Gastroenterology Gall Bladder Surgical Gastroenterology Gall Bladder Surgical Gastroenterology Gall Bladder Surgical Gastroenterology Spleen Surgical Gastroenterology Spleen Surgical Gastroenterology Spleen Surgical Gastroenterology Pancreas Surgical Gastroenterology Pancreas Surgical Gastroenterology Pancreas
75000
205
30000
206
45000
207
25000
208
45000
209 210
35000 35000
211
60000
212 213
35000 100000
214
100000
215
100000
~ 78 ~

Indicativ e Rate &
216
Surgical Gastroenterology Pancreas Surgical Gastroenterology Pancreas Surgical Gastroenterology Pseudocyst Surgical Gastroenterology Pseudocyst Card iology Card iology Card iology
217
218
Distal Pancreatectomy + Splenecto my Inv - CTScan , ERCP , ERClinical Photograph , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy Central Pancreatectomy Inv - CT-Scan , ERCP , ERClin ical Photograph , Endoscopy Post procedure evidence of Clin ical photograph,Biopsy Cysto Jejunostomy Inv - CT , USG Post procedure evidence of Clinical photograph,Biopsy Cysto Gastrostomy Inv - CT , USG Post procedure evidence of Clinical photograph,Biopsy Coronary ballon Angioplasty Inv - 2 CAD Post procedure evidence of Clin ical photograph PTCA Addit ional Stent Inv - CA G Post procedure evidence of Clin ical photograph ASD Device closure Inv - 2D ECHO Post procedure evidence of Clin ical photograph, 2D Echo VSD Device closure Inv - 2D ECHO Post procedure evidence of Clin ical photograph, 2D Echo PDA Stenting Inv - 2D ECHO Post procedure evidence of Clin ical photograph, 2D Echo PDA Device closure Inv - 2D ECHO Post procedure evidence of Clin ical photograph, 2D Echo Coil Closure Single coil Inv - 2D ECHO Post procedure evidence of Clin ical photograph, 2D Echo Coil Closure Multiple co ils Inv - 2D ECHO Post procedure evidence of Clin ical photograph, 2D Echo Balloon Valvotomy Inv - 2D ECHO Post procedure evidence of Clin ical photograph, 2D Echo Balloon Atrial septostomy Inv - 2D ECHO Post procedure evidence of Clin ical photograph, 2D Echo Permanent pacemaker imp lantation Inv - CA G , ECG Post procedure evidence of Clin ical photograph, 2D Echo Temporary pacemaker imp lantation Inv - CA G , ECG Post procedure evidence of Clin ical photograph, 2D Echo Coarctation of Aorta Repair With stent Inv - 2D ECHO , CA G Post procedure evidence of Clin ical photograph, Doppler Coarctation of Aorta Repair Without stent Inv Aortogram Post procedure evidence of Clin ical photograph, Doppler
100000
40000
219 220 221 222
40000 60000 20000 80000
223
Card iology
80000
224 225
Card iology Card iology
65000 60000
226 227
20000 30000
228
Card iology Balloon procedures Card iology Balloon procedures Card iology Pacemaker implantation Card iology Pacemaker implantation Card iology Coarctation of Aorta repair / Aortoplasty Card iology Coarctation of Aorta repair / Aortoplasty
20000
229 230
30000 75000
231
10000
232
80000
233
30000
~ 79 ~

Indicativ e Rate &
234
Card iology Angioplasty Card iology Angioplasty Card iology Angioplasty Card iology Angioplasty CVTS Surgery fo r CAD CVTS Surgery fo r CAD CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries
235 236
237
238
239
240
Renal Angioplasty Inv - Angiogram Post procedure evidence of Clin ical photograph, Doppler Peripheral Angioplasty Inv - 2D ECHO , Angiogram Post procedure evidence of Clinical photograph, Doppler Vertebral Angioplasty Inv - Angiogram Post procedure evidence of Clin ical photograph, Doppler Angioplasty Additional Stent Inv - Angiogram Post procedure evidence of Clin ical photograph, Doppler Coronary bypass Surgery on pump with IABP Inv - CA G, 2D ECHO Post procedure evidence of Clin ical photograph Coronary bypass Surgery off pu mp with IA BP Inv - 2D ECHO Post procedure evidence of Clinical photograph. Peripheral embolecto my without graft Inv Angiogram , Sp iral CT Angiogram Post procedure evidence of Colo r Doppler Excision of A V Malformat ion Large Inv - M RI Angiogram , Sp iral CT Angiogram Post procedure evidence of Colo r Doppler Excision of A V Malformat ion Small Inv - M RI Angiogram , Sp iral CT Angiogram Post procedure evidence of Colo r Doppler Arterial embolecto my Inv - Angiogram , Co lor Doppler Post procedure evidence of Colo r Doppler/SBP/PVR A V Fistula at Wrist Inv - Co lor Doppler Post procedure evidence of Color Doppler A V Fistula at Elbow Inv - Color Doppler Post procedure evidence of Color Doppler D V T - IVC Filter Inv - Color Doppler Post procedure evidence of Plain X-Ray abdomen, Clin ical photograph Vascular tumours Inv - Angiogram , Spiral CT Post procedure evidence of Colo r Doppler Small arterial aneurysms - Repair Inv Angiogram , Sp iral CT Pos t procedure evidence of Color Doppler Medium size arterial aneurysms - Repair Inv Angiogram , Sp iral CT Post procedure evidence of Color Doppler Medium size arterial aneurysms with s ynthetic graft Inv - Angiogram , Spiral CT Post procedure evidence of Colo r Doppler Aorto Billac - Bifemoral bypass with synthetic graft Inv - Angiogram , Spiral CT Post procedure evidence of Colo r Doppler
60000 75000
40000
150000
150000
25000
241
75000
242
40000
243
20000
244 245 246
10000 20000 100000
247 248
40000 15000
249 250
50000 75000
251
125000
~ 80 ~

Indicativ e Rate &
252
CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS Vascular Surgeries CVTS - Surgery for Card iac injuries CVTS - surgery for Card iac injuries CVTS - Surgery for CAD CVTS - Surgery for CAD CVTS - Surgery for CAD CVTS Valve replacement CVTS Valve replacement CVTS Valve replacement CVTS Valve replacement CVTS Pericard iu m CVTS Pericard iu m CVTS Pericard iu m CVTS Coarctation of Aorta repair CVTS Coarctation of Aorta repair CVTS Aorta repair
253 254
255
Axillo Bifemo ral Bypass with synthetic graft Inv Angiogram , Sp iral CT Post procedure evidence of Color Doppler Femorodistal Bypass with vein graft Inv Angiogram , Sp iral CT Post procedure evidence of Color Doppler Femorodistal Bypass with synthetic graft Inv Angiogram , Sp iral CT Post procedure evidence of Color Doppler Axillo b rachial bypass using with synthetic graft Inv - Angiogram , Spiral CT Post procedure evidence of Colo r Doppler Brach ioradial bypass with synthetic graft Inv Angiogram , Sp iral CT Post procedure evidence of Color Doppler Carotid body tumour Excision Inv - Angiogram , Spiral CT Post procedure evidence of Color Doppler Carotid artery bypass with synthetic graft Inv Angiogram , Sp iral CT Post procedure evidence of Color Doppler Surgery without CPB Inv - 2D Echo Post procedure evidence of 2D Echo Surgery with CPB Inv - 2D Echo Post procedure evidence of 2D Echo CABG on pu mp without IABP Inv - 2D ECHO , CA G Post procedure evidence of Clinical photograph CABG o f pu mp without IABP Inv - 2D ECHO , CA G Post procedure evidence of Clinical photograph CABG with aneurysmal repair Inv - CA G Post procedure evidence of Clin ical photograph Mitral valve rep lacement (with valve) Inv - 2D ECHO Post procedure evidence of 2D Echo Aortic valve replacement (with valve) Inv - 2D ECHO Post procedure evidence of 2D Echo Tricuspid valve replacement Inv - 2D ECHO Post procedure evidence of 2D Echo Double valve rep lacement (with valve) Inv - 2D ECHO Post procedure evidence of 2D Echo Percardiostomy Inv - 2D ECHO Post procedure evidence of 2D Echo Percardectomy Inv - 2D ECHO Post procedure evidence of 2D Echo Pericardiocentesis Inv - 2D ECHO Post procedure evidence of 2D Echo Coarctation of aorta Repair with graft Inv - 2D ECHO , CA G Post procedure evidence of Doppler Coarctation of aorta Repair without graft Inv - 2D ECHO , CA G Post procedure evidence of Doppler Aneurysm resection & grafting Inv - 2D ECHO , CA G Post procedure evidence of Doppler
60000 80000
65000
256 257
50000 60000
258
100000
259 260 261
40000 75000 125000
262
125000
263 264 265 266 267 268 269 270 271 272 273
110000 120000 120000 120000 150000 10000 30000 2000 32000 25000 125000
~ 81 ~

Indicativ e Rate &
274
CVTS Aorta repair
275 276 277 278 279 280 281 282 283 284 285 286 287 288 289
CVTS Aorta repair CVTS Aorta repair CVTS Aorta repair CVTS CVTS CVTS CVTS CVTS CVTS CVTS CVTS CVTS CVTS CVTS CVTS
Intrathoracic Aneurysm-Aneurysm not requiring bypass (with graft) Inv - CT-Angio , Cath Post procedure evidence of Doppler Intrathoracic Aneurysm-Aneurysm requiring bypass (with graft) Inv - CT-Angio , Cath Post procedure evidence of Doppler Dissecting Aneurysms Inv - CT-Angio , Cath Post procedure evidence of Doppler Annulus aortic ectasia with valved conduits Inv Angio Post procedure evidence of Echo, Doppler Aorto-aorto bypass with graft Inv - Angio Post procedure evidence of Doppler Aorto-aorto bypass without graft Inv - Angio Post procedure evidence of Doppler Femoro popliteal bypass with graft Inv - Angio Post procedure evidence of Doppler Femoro popliteal bypass without graft Inv - Angio Post procedure evidence of Doppler Femoroileal bypass With Graft Inv - Angio Post procedure evidence of Doppler Femoroileal bypass Without Graft Inv - Angio Post procedure evidence of Doppler Femoro-femo ral bypass With Graft Inv - Angio Post procedure evidence of Doppler Femoro-femo ral bypass Without Graft Inv Angio Post procedure evidence of Doppler TGA Arterial Switch Inv - 2D ECHO , angio Post procedure evidence of 2D Echo TGA Sennings Procedure Inv - 2D ECHO , angio Post procedure evidence of 2D Echo Carotid Embolecto my Inv - Angiogram Post procedure evidence of Doppler Surgery for Intracardiac tu mours Inv - 2D ECHO , CA G Post procedure evidence of Echo/HPE/ Clin ical photograph Ruptured sinus of valsalva correction Inv - CA G Post procedure evidence of Echo/Clinical photograph TAPVC correction Inv - 2D ECHO Post procedure evidence of Echo/Clin ical photograph Systemic pulmonary Shunts with graft Inv - 2D ECHO Post procedure evidence of 2D ECHO Systemic pulmonary Shunts without graft Inv - 2D ECHO Post procedure evidence of 2D ECHO Total correction of Tetralogy of Fallots Inv - 2D ECHO Post procedure evidence of Clinical photograph/Echo Intracardiac Repair of ASD Inv - 2D ECHO Post procedure evidence of 2D ECHO Intracardiac Repair of VSD Inv - 2D ECHO Post procedure evidence of 2D ECHO
125000 75000 150000 60000 45000 45000 30000 45000 25000 45000 25000 150000 120000 50000 75000
290
CVTS
95000
291 292 293 294
CVTS CVTS Systemic Pulmonary shunts CVTS Systemic Pulmonary shunts CVTS Systemic Pulmonary shunts CVTS CVTS
95000 20000 20000 95000
295 296
75000 75000
~ 82 ~

Indicativ e Rate &
297 298
CVTS CVTS Ross procedure Intracardiac repair o f complex congenital heart diseases CVTS Ross procedure Intracardiac repair o f complex congenital heart diseases CVTS Valve repairs CVTS Valve repairs CVTS Valve repairs CVTS Valve repairs CVTS Valve repairs CVTS Lungs CVTS Lungs CVTS Lungs CVTS Lungs CVTS Lungs CVTS Surgical correction of Bronchopleural fistula CVTS Surgical correction of Bronchopleural fistula CVTS Surgical correction of Bronchopleural fistula CVTS Chest CVTS Chest
Surgery-PDA Inv - 2D ECHO Post procedure evidence of 2D ECHO With special conduits Inv - 2D ECHO Post procedure evidence of 2D ECHO
Upper ceiling (Rs.) 20000 125000
299
Without special conduits Inv - 2D ECHO Post procedure evidence of 2D ECHO
95000
300 301 302 303 304 305 306 307 308 309 310
With prosthetic ring Inv - 2D ECHO Post procedure evidence of 2D ECHO Without prosthetic ring Inv - 2D ECHO Post procedure evidence of 2D ECHO Open pulmonary valvotomy Inv - 2D ECHO Post procedure evidence of 2D ECHO Closed mit ral valvotomy Inv - 2D ECHO Post procedure evidence of 2D ECHO Mitral valvotomy (Open) Inv - 2D ECHO Post procedure evidence of 2D ECHO Pneumonectomy Inv - CT-Chest , X-Ray Post procedure evidence of Clin ical Photograph/X-Ray Lobectomy Inv - CT-Chest , X-Ray Post procedure evidence of Clin ical Photograph/X-Ray Decortication Inv - CT-Chest , X-Ray Post procedure evidence of Clin ical Photograph/X-Ray Lung cyst Inv - CT-Chest , X-Ray Post procedure evidence of Clin ical Photograph/X-Ray SOL Mediastinum Inv - CT-Chest , X-Ray Post procedure evidence of Clin ical Photograph/X-Ray Thorocoplasty Inv - CT-Chest , X-Ray Post procedure evidence of Clin ical Photograph/X-Ray Myoplasty Inv - CT-Chest , X-Ray Post procedure evidence of Clin ical Photograph/X-Ray Transpleural BPF Closure Inv - CT-Chest , X-Ray Post procedure evidence of Clin ical Photograph/X-Ray Diaphrag matic Eventeration Inv - Bariu m studies , CT-Scan Post procedure evidence of USG Diaphrag matic Hernia Inv - CT-Scan , USG Post procedure evidence of USG
100000 85000 75000 20000 80000 50000 50000 50000 50000 50000 50000
311
50000
312
50000
313 314
40000 40000
~ 83 ~

Indicativ e Rate &
315
CVTS Chest
316 317
CVTS Diaphrag matic injuries CVTS Bronchial injuries CVTS Bronchial injuries CVTS Oesophagus injuries
318
Oesophageal diverticula /Achlasia cardia Inv Bariu m studies , CT-Scan Post procedure evidence of USG Thoracotomy, Thoraco abdominal approach Inv CT-Scan Post procedure evidence of Clin ical photograph with operative scars Foreign body removal with scope Inv Bronchoscopy , CT-Scan Post procedure evidence of Endoscopic picture Repair surgery Injuries due to Foreign body Inv Bronchoscopy , CT-Scan Post procedure evidence of Endoscopic picture Gastro study followed by Thoracotomy and repairs for oesophageal injury fo r Corrosive Injuries/FB Inv - Gastroscopy Post procedure evidence of Endoscopic picture Surgery without graft for Arterial injuries, venous injuries Inv - Angiogram , Doppler Post procedure evidence of Clin ical photograph with scar Vascular In jury in upper limbs Axillary,branchial,Radial and Ulnar - Repair with Vein Graft Inv - Angiogram , Doppler Post procedure evidence of Color doppler Major Vascular Inju ry -in lo wer limbs-Repair Inv - Angiogram , Doppler Post procedure evidence of Co lor doppler Minor Vascular Injury Repair- Tibial vessels in leg Inv - Angiogram , Doppler Post procedure evidence of Colo r doppler Minor Vascular Injury Repair -vessels in Foot Inv - Angiogram , Doppler Post procedure evidence of Co lor doppler Surgery with Vein graft Inv - Angiogram , Doppler Post procedure evidence of Clinical photograph with scar Color doppler With prosthetic graft Inv - Angiogram , Doppler Post procedure evidence of Clin ical photograph with scar Neck vascular injury - Carot id vessels Inv Angiogram , Doppler Post procedure evidence of Color Doppler Abdominal vascular injuries - Aorta, Iliac arteries, IVC, Iliac veins Inv - Angiogram , Doppler Post procedure evidence of Color doppler Thoracic vascular in juries Inv - Angiogram , Doppler Post procedure evidence of Colo r doppler Oesophageal atresis Inv - X-Ray, Oesophagoscopy Post procedure evidence of Clin ical Photograph
40000 20000
40000
319
50000
320
CVTS Vascular Injuries
10000
321
CVTS Vascular Injuries
Up to 40000
322 323
CVTS Vascular Injuries CVTS Vascular Injuries CVTS Vascular Injuries CVTS Vascular Injuries CVTS Vascular Injuries CVTS Vascular Injuries CVTS Vascular Injuries CVTS Vascular Injuries Pediatric Surgeries Congenital malfo rmations - GI Tract
Up to 60000 Up to 20000 Up to 20000 15000 40000
324
325 326
327
Up to 100000 Up to 100000 Up to 150000 60000
328
329 330
~ 84 ~

Indicativ e Rate &
331
332
333
334
335
336
337
338
339
340
341
342
343
344
Pediatric Surgeries Congenital malfo rmations - GI Tract Pediatric Surgeries Congenital malfo rmations - GI Tract Pediatric Surgeries Congenital malfo rmations - GI Tract Pediatric Surgeries Congenital malfo rmations - GI Tract Pediatric Surgeries Congenital malfo rmations - GI Tract Pediatric Surgeries Congenital malfo rmations - GI Tract Pediatric Surgeries Congenital malfo rmations - GI Tract Pediatric Surgeries Congenital malfo rmations Urogenital Pediatric Surgeries Congenital malfo rmations Urogenital Pediatric Surgeries Congenital malfo rmations Urogenital Pediatric Surgeries Congenital malfo rmations Urogenital Pediatric Surgeries Congenital malfo rmations Urogenital Pediatric Surgeries Congenital malfo rmations Urogenital Pediatric Surgeries Congenital malfo rmations Urogenital
Diaphrag matic hernia Inv - USG, CT Post procedure evidence of Clin ical Photograph
Intestinal atresias & Obstructions Inv - x-Ray, CT Post procedure evidence of Clin ical Photograph
50000
Biliary atresis & Choledocal cyst Inv - CT, Clin ical Photograph Post procedure evidence of Clin ical Photograph Anorectal malformations Stage 1 Inv - Clin ical Photograph, Proctoscopy Post procedure evidence of Clinical Photograph Anorectal malformations Stage 2 Inv - Clin ical Photograph, Proctoscopy Post procedure evidence of Clinical Photograph Hirschsprung Disease Stage 1 Inv - Clinical Photograph, Proctoscopy Biopsy Post procedure evidence of Clin ical Photograph Hirschsprung Disease Stage 2 Inv - Clinical Photograph, Proctoscopy Biopsy Post procedure evidence of Clin ical Photograph Congenital hydronephrosis Inv USG/ IVP/Renogram Post procedure evidence of Clin ical Photograph, IVP Ureteric reimp lantations Inv - Clinical Photograph/USG Post procedure evidence of Clin ical Photograph,IVP Extrophy bladder Stage 1 Inv - Clin ical Photograph/USG Post procedure evidence of Clin ical Photograph Extrophy bladder Stage 2 Inv - Clin ical Photograph/USG Post procedure evidence of Clin ical Photograph Posterior urethral valves Inv - MCU Post procedure evidence of Clin ical Photograph,IVP
55000
45000
60000
45000
60000
50000
65000
65000
60000
30000
Hypospadias single stage Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph Hypospadius stage 2 Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph
40000
35000
~ 85 ~

Indicativ e Rate &
345
346
347
348
349
350
351
352
353 354
355
356 357
Pediatric Surgeries Congenital malfo rmations Pediatric Surgeries Congenital malfo rmations Plastic repair Pediatric Surgeries Congenital malfo rmations Plastic repair Pediatric Surgeries Congenital malfo rmations Plastic repair Pediatric Surgeries Congenital malfo rmations Plastic repair Pediatric Surgeries Congenital malfo rmations Plastic repair Pediatric Surgeries Congenital malfo rmations Plastic repair Pediatric Surgeries Congenital malfo rmations Urogenital Pediatric Surgeries Congenital malfo rmations Pediatric Surgeries Congenital malfo rmations Pediatric Surgeries Congenital malfo rmations Pediatric Surgeries Head and neck Pediatric Surgeries Head and neck Pediatric Surgeries Head and neck Pediatric Surgeries Head and neck Pediatric Surgeries Head and neck
Pediatric tumours Inv - CT/Biopsy Post procedure evidence of Clin ical Photograph Cleft lip Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph
10000
Cleft palate Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph
15000
Velo-Pharyngial Inco mpetence Inv - Endoscopy Post procedure evidence of Clin ical Photograph
15000
Syndactyly of hand for each hand Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph Microtia/ Anotia Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph
15000
30000
TM joint anky losis Inv -Clinical Photograph / XRay Post procedure evidence of Clin ical Photograph Hypospadius stage 1 Inv - Clinical Photograph Post procedure evidence of Clin ical Photograph
40000
35000
Hamarto ma Excision Inv - CT/ Clinical Photograph Post procedure evidence of Clin ical Photograph Hemangio ma Excision Inv - Neuro USG+CT Post procedure evidence of Clin ical Photograph Ly mphangio ma Excision Inv -Neuro USG+CT Post procedure evidence of Clin ical Photograph Neuroblastoma Inv - CT/USG/FNAC Post procedure evidence of Clin ical Photograph,Biopsy Congenital Dermal Sinus Inv - Neuro USG+CT Post procedure evidence of Clin ical Photograph,Biopsy Cystic Lesions of the Neck Inv USG,M RI,CT,Clin ical Photograph Post procedure evidence of Clin ical Photograph,Biopsy Encephalocele Inv - Neuro USG+CT Post procedure evidence of Clin ical Photograph,Biopsy Sinuses & Fistula of the Neck Inv - CT,Clinical Photograph Post procedure evidence of Clinical Photograph,Biopsy
20000 25000
40000
25000 30000
358
20000
359 360
20000 20000
~ 86 ~

Indicativ e Rate &
361
Pediatric Surgeries Chest Pediatric Surgeries Chest Pediatric Surgeries Chest Pediatric Surgeries Chest Pediatric Surgeries Chest Pediatric Surgeries Chest Pediatric Surgeries Chest Pediatric Surgeries Abdomen Pediatric Surgeries Abdomen Pediatric Surgeries Abdomen Pediatric Surgeries Abdomen Pediatric Surgeries Abdomen Pediatric Surgeries Abdomen Pediatric Surgeries Abdomen Pediatric Surgeries Abdomen Pediatric Surgeries Abdomen Pediatric Surgeries Abdomen Pediatric Surgeries Abdomen
362 363
364 365 366 367
Bronchoscopy foreign body removal Inv Endoscopic Video Post procedure evidence of Clin ical Photograph Paediatric Esophageal obstructions -Surgical correction Inv -Contrast UGI Post procedure evidence of Clin ical Photograph Paediatric Esophageal Substitutions Inv - Contrast study Post procedure evidence of Clinical Photograph Thoracoscopic cysts excision Inv - USG, CT Post procedure evidence of Clin ical Photograph/Biopsy Thoracoscopic decortication Inv - USG, CT Post procedure evidence of Clin ical Photograph/Biopsy Thoracic Duplications Inv - X-Ray, CT Post procedure evidence of Clin ical Photograph/Biopsy Thoracic Wall defects- Co rrection Inv - X-Ray, CT Post procedure evidence of Clinical Photograph Gastric outlet obstructions Inv - Contrast USG, XRay Post procedure evidence of Clin ical Photograph Laparoscopic pull through surgeries for HD Inv USG,Clin ical Photograph Post procedure evidence of Clinical Photograph,USG, Video Paediatric Splenecto my (Non Trau matic) Inv USG,Hemogram Post procedure evidence of Clin ical Photograph Surgeries on adrenal gland in Children Inv - CT, Hormone assays Post procedure evidence of Clin ical Photograph,USG Gastro Esophageal Reflu x Correction Inv Endoscopy, CT Scan Post procedure evidence of Clin ical Photograph Hydatid cysts in Paediatric patient Inv - CT,USG Post procedure evidence of Clin ical Photograph,USG Intestinal Polyposis Surgical correct ion Inv UG,Endoscopy Post procedure evidence of Clin ical Photograph,Biopsy Intussusception Inv - USG,CT Post procedure evidence of Clin ical Photograph,USG Paediatric Acute Intestinal Obstruction Inv USG,CT Post procedure evidence of Clinical Photograph,USG Laparoscopic Appendectomy Inv - USG,Clin ical Photograph Post procedure evidence of Clin ical Photograph,USG,Video Laparoscopic Choleycystectomy Inv USG,Clin ical Photograph Post procedure evidence of Clinical Photograph,USG,Video
30000 60000
40000 40000 40000 50000
368 369
30000 60000
370
35000
371 372
25000 30000
373
40000
374 375 376 377
50000 40000 40000 30000
378
40000
~ 87 ~

Indicativ e Rate &
379
Pediatric Surgeries Abdomen
380
Pediatric Surgeries Urogenital Pediatric Surgeries Urogenital Pediatric Surgeries Urogenital Pediatric Surgeries Urogenital Pediatric Surgeries Urogenital Pediatric Surgeries Urogenital Pediatric Surgeries Urogenital Urology Renal Transplantation Urology Renal Transplantation Urology Renal Transplantation Urology Testis, Testis and Penis Urology Testis, Testis and Penis Urology Testis, Testis and Penis Urology Testis, Testis and Penis Urology Testis, Testis and Penis Urology Renal Calculi Urology Renal Calculi Urology Renal Calculi
381 382 383 384
385
386 387
388 389
Laparoscopic pull through for Ano Rectal Anomalies Inv - USG,Clin ical Photograph Post procedure evidence of Clin ical Photograph,USG,Video Nephrectomy Inv - USG,CT,Clinical Photograph Post procedure evidence of Clin ical Photograph,USG Ep ispadiasis - Correct ion Inv - Clin ical Photograph Post procedure evidence of Clin ical Photograph Scrotal transposition repair Inv - USG Post procedure evidence of Clin ical Photograph Undescended Testis Inv - USG,Clinical Photograph Post procedure evidence of Clin ical Photograph Torsion Testis Inv - Color doppler, Clin ical Photograph Post procedure evidence of Clin ical Photograph Laparoscopic Orch idopexy Inv - USG,Clin ical Photograph Post procedure evidence of Clin ical Photograph,USG,Video Laparoscopic Varicocele ligation Inv USG,Clin ical Photograph Post procedure evidence of Clinical Photograph,USG,Video A.V. Fistula (Pretransplant procedure only) Inv Renal function tests, Serum electro lytes Post procedure evidence of Clin ical photograph Renal t ransplantation surgery Inv - USG,RFT Post procedure evidence of Clin ical photograph Post-transplant immunosuppression treatment Fro m 1st to 6th month after transplantation Inv USG,RFT Post procedure evidence of Bills copy Orchidopexy Bilateral Inv - USG Post procedure evidence of Clin ical photograph Torsion testis Inv -USG Post procedure evidence of Clinical photograph Chordae correction Inv - USG Post procedure evidence of Clin ical photograph Partial amputation of Pen is(Non-Malignant) Inv Clin ical Photograph Post procedure evidence of Clin ical photograph,Biopsy Total amputation of Penis(Non-Malignant) Inv Clin ical Photograph Post procedure evidence of Clin ical photograph,Biopsy Open Pyelolithotomy Inv - USG,KUB,IVP Post procedure evidence of Clin ical photograph,XRay,USG Open Nephrolithotomy Inv - USG,KUB,IVP Post procedure evidence of Clin ical photograph,XRay,USG Open cystolithotomy Inv - USG,KUB,IVP Post procedure evidence of Clin ical photograph,XRay,USG
40000
40000 20000 25000 25000
25000
25000 10000
140000 50000
390 391 392 393 394
15000 12000 15000 15000 25000
395
10000
396 397
10000 10000
~ 88 ~

Indicativ e Rate &
398
Urology Renal Calculi Urology Lithotripsy Urology Lithotripsy Urology Lithotripsy Urology Lithotripsy Urology Lithotripsy Urology Lithotripsy Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology
399 400 401 402 403 404 405
Laparoscopic Pyelolithotomy Inv USG,KUB,IVP Post procedure evidence of Clin ical photograph,X-Ray,Video Cystolithotripsy Inv - USG,KUB Post procedure evidence of Clin ical photograph,X-Ray,USG PCNL Inv - USG,KUB,IVP Post procedure evidence of Clin ical photograph,X-Ray ESWL Inv - USG,KUB,IVP Post procedure evidence of Clin ical photograph,X-Ray,IVP URSL Inv - USG,KUB,IVP Post procedure evidence of Clin ical photograph,X-Ray Nephrostomy Inv -USG,IVP Post procedure evidence of Clin ical photograph DJ Stent (One side) Inv - USG,IVP Post procedure evidence of X-Ray Urethroplasty for Stricture Urethra Single stage Inv - RUG Post procedure evidence of Clinical photograph Urethroplasty for Stricture Urethra Double Stage Stage-1 Inv - RUG Post procedure evidence of Clin ical photograph Urethroplasty for Stricture Urethra Double Stage Stage-2 Inv - RUG Post procedure evidence of Clin ical photograph Urethroplasty for Stricture Urethra Double Stage Reconstruction Procedure Inv - Clinical Photograph Post procedure evidence of Photo Hypospadius Adult Single Stage Inv - Clin ical Photograph Post procedure evidence of Clinical photograph Hypospadius Adult Double Stage - Stage-1 Inv Clin ical Photograph Post procedure evidence of Clin ical photograph Hypospadius Adult Double Stage - Stage-2 Inv Clin ical Photograph Post procedure evidence of Clin ical photograph Hypospadius Adult Double Stage - TURBT Inv CT,USG,Cysoscopy, Biopsy Post procedure evidence of Clin ical photograph, CT Post-Transplant immunosuppressive Treatment fro m 7th to 12 th Month after transplantation Inv USG/ RFT Post procedure evidence of Bills copy Nephrostomy Inv - USG,IVP Post procedure evidence of USG Nephrectomy Pyonephrosis/XGP Inv - USG,IVP Post procedure evidence of USG Simp le Nephrectomy Inv - USG,IVP Post procedure evidence of USG Lap. Nephrectomy Simple Inv - USG,IVP Post procedure evidence of USG Lap. Nephrectomy Rad ical Inv - USG,IVP Post procedure evidence of USG
10000 30000 20000 25000 2000 5000 50000
406
30000
407 408
30000 50000
409
40000
410
35000
411
35000
412
30000
413
50000
414 415 416 417 418
Urology Kidney Urology Kidney Urology Kidney Urology Kidney Urology Kidney
10000 40000 40000 30000 40000
~ 89 ~

Indicativ e Rate &
419 420 421 422
Urology Kidney Urology Kidney Urology Kidney Urology Kidney Stone Urology Kidney Stone Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Correct ive procedures Urology Bladder Prostate Urology Bladder Prostate Urology Bladder Prostate Urology Bladder Prostate Urology Bladder Prostate Urology Bladder Prostate Urology Bladder Prostate Urology Bladder Prostate Neurosurgery Brain
Lap. Part ial Nephrectomy Inv -USG,IVP Post procedure evidence of USG Bilateral Nephroureterectomy Inv - USG,IVP Post procedure evidence of USG Renal Cyst Excision Inv - USG,IVP Post procedure evidence of USG Endoscope Removal of stone in Bladder Inv USG, IVP,Scopy. X-Ray. KUB Post procedure evidence of Endoscopic picture Anatrophic Pyelolithotomy fo r Staghorn Calculus Inv - USG,KUB,IVP Post procedure evidence of Clin ical photograph/X-Ray, USG Anderson Hynes Pyeloplasty Inv - X-Ray, USG,IVP Post procedure evidence of Clin ical photograph Vasico Vaginal Fistula Inv - IVP,Scopy, RGP Post procedure evidence of Clin ical photograph Ep ispadiasis - Correct ion Inv - Clin ical photograph Post procedure evidence of Clinical photograph Closure of Urethral Fistula Inv - RGU Post procedure evidence of Clin ical photograph Optical Urethrotomy Inv - X-Ray, RGU Post procedure evidence of Endoscopic picture Perineal Urethrostomy Inv -X-Ray, RGU Post procedure evidence of Endoscopic picture Ureteric Reimplantation Inv -X Ray,USG,IVP Post procedure evidence of USG Ileal Conduit format ion Inv - X Ray,USG,IVP Post procedure evidence of Clin ical photograph Ureterocele Inv - X Ray,RGU Post procedure evidence of Clin ical photograph Transurethral resection of prostate (TURP) Inv USG,U.Scopy Post procedure evidence of USG TURP Cyst lithotripsy Inv - X-Ray,USG Post procedure evidence of USG Open prostatectomy Inv - X-Ray,USG Post procedure evidence of Clin ical photograph Caecocystoplasty Inv - USG,U.Scopy Post procedure evidence of USG Total cystectomy Inv -USG,U.Scopy Post procedure evidence of USG Divert iculecto my Inv -USG,U.Scopy Post procedure evidence of USG Incontinence Urine (Female) Inv -USG,U.Scopy Post procedure evidence of USG Incontinence Urine (male) Inv - USG,U.Scopy Post procedure evidence of USG Cran iotomy and evacuation of Hemato ma Subdural Inv - CT Post procedure evidence of Clin ical photograph Cran iotomy and evacuation of Hemato ma Extradural Inv - CT Post procedure evidence of
Upper ceiling (Rs.) 35000 25000 15000 10000
423
50000
424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441
40000 40000 40000 25000 20000 20000 25000 20000 15000 30000 30000 30000 30000 35000 10000 20000 20000 40000
442
Neurosurgery Brain
40000
~ 90 ~

Indicativ e Rate &
Upper ceiling (Rs.) Clin ical photograph
443 444
Neurosurgery Brain Neurosurgery Brain
445
Neurosurgery Brain Tumours Neurosurgery Brain Tumours Neurosurgery Brain Tumours Neurosurgery Brain Tumours Neurosurgery Excision of Brain tumours Neurosurgery Excision of Brain Tumours Neurosurgery Excision of Brain Tumours Neurosurgery Excision of Brain Tumours Neurosurgery Excision of Brain Tumours Neurosurgery Excision of Brain Tumours Neurosurgery Excision of Brain Tumours Neurosurgery Excision of Brain Tumours Neurosurgery Excision of Brain Tumours Neurosurgery Excision of Brain Tumours Neurosurgery Brain Tumours Neurosurgery Brain Tumours
Evacuation of Brain Abscess - Bu rr hole Inv - CT Post procedure evidence of Clin ical photograph Excision of Lobe (Frontal,Temporal,Cerebellu m etc.) Inv - CT Post procedure evidence of Clin ical photograph/Biopsy Parasagittal Inv - CT Post procedure evidence of Clin ical photograph/Biopsy Basal Inv - CT Post procedure evidence of Clin ical photograph/Biopsy Brain Stem Inv -CT Post procedure evidence of Clin ical photograph/Biopsy C P Angle Inv - CT Post procedure evidence of Clin ical photograph/Biopsy Others Inv -CT Post procedure evidence of Clin ical photograph/Biopsy Excision of b rain tu mours Subtentorial Inv - CT Post procedure evidence of Clin ical photograph/Biopsy Ventriculo lateral / Ventriculoperitoneal shunt Inv - CT Post procedure evidence of Clinical photograph Twist drill craniotomy Inv -CT Post procedure evidence of Clin ical photograph Subdural taping Inv - CT Post procedure evidence of Clinical photograph Ventricular tapping Inv - CT Post procedure evidence of Clin ical photograph Abscess tapping Inv - CT Post procedure evidence of Clinical photograph Vascular malformations Inv - M RI,Angio Post procedure evidence of Clin ical photograph Peritoneal shunt Inv - CT Post procedure evidence of Clinical photograph Atrial shunt Inv - CT Post procedure evidence of Clin ical photograph Meningoencephalocele Inv - M RI Post procedure evidence of Clin ical photograph Meningomylocele Inv - M RI Post procedure evidence of Clin ical photograph
25000 40000
50000
446
60000
447
70000
448
70000
449
40000
450
45000
451
20000
452 453
15000 15000
454
15000
455 456
20000 40000
457
20000
458 459 460
20000 25000 25000
~ 91 ~

Indicativ e Rate &
461 462 463 464 465 466 467 468 469
Neurosurgery Brain Tumours Neurosurgery Brain Tumours Neurosurgery Brain Tumours Neurosurgery Brain Tumours Neurosurgery Brain Tumours Neurosurgery Brain Tumours Neurosurgery Brain Tumours Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery Spinal Surgeries Neurosurgery - Other Surgical Procedures Neurosurgery - Other Surgical Procedures Neurosurgery - Other Surgical Procedures
C.S.F. Rhinorrhoea Inv -CT,Clin ical photograph Post procedure evidence of Clin ical photograph Cran ioplasty Inv - MRI Post procedure evidence of Clinical photograph Meningocele excision Inv - MRI Post procedure evidence of Clin ical photograph Ventriculoatrial shunt Inv - CT Post procedure evidence of Clin ical photograph Excision of Brain Abscess - Inv -CT Post procedure evidence of Clin ical photograph Aneurysm Clipping Inv -M RI,Angio Post procedure evidence of Clin ical photograph, X-Ray External Ventricular Drainage (EVD) Inv - CT Post procedure evidence of Clin ical photograph Surgery on cord tumours Inv - M RI Post procedure evidence of Clin ical photograph/Biopsy Spinal intramedullary tu mours Inv -M RI Post procedure evidence of Clin ical photograph/XRay/Biopsy Spina bifida surgery major Inv -MRI Post procedure evidence of Clin ical photograph/X-Ray Spina bifida surgery minor Inv - MRI Post procedure evidence of Clin ical photograph/X-Ray Excision of cervical intervertebral d iscs Inv - MRI Post procedure evidence of Clin ical photograph Posterior cervical discectomy Inv - M RI Post procedure evidence of Clin ical photograph Anterior cervical discectomy Inv - M RI Post procedure evidence of Clin ical photograph Anterior cervical spine surgery with fusion Inv MRI, X-Ray Cervical spine Post procedure evidence of X-Ray Anterolateral decompression Inv -MRI Post procedure evidence of Clin ical photograph/X-Ray Laminectomy Inv - M RI Post procedure evidence of Clinical photograph/X-Ray Discectomy Inv - M RI Post procedure evidence of Clin ical photograph/X-Ray Spinal fusion procedure Inv - MRI Post procedure evidence of Clin ical photograph/Biopsy Stereotactic procedures - Post procedure evidence of Clinical photograph Trans sphenoidal surgery Inv - CT Post procedure evidence of Clin ical photograph/Biopsy Trans oral surgery Inv - CT Post procedure evidence of Clin ical photograph/Biopsy
Upper ceiling (Rs.) 20000 30000 25000 20000 60000 100000 40000 25000 50000
470 471 472 473 474 475
20000 15000 25000 15000 15000 45000
476 477 478 479 480 481 482
30000 25000 25000 50000 20000 20000 25000
~ 92 ~

Indicativ e Rate &
483
Neurosurgery - Other Surgical Procedures Neurosurgery - Other Surgical Procedures Neurosurgery Brain Neurosurgery Brain Neurosurgery Brain Neurosurgery Brain Neurosurgery Spine Neurosurgery Spine Neurosurgery Spine Neurosurgery Spine Neurosurgery Spine Neurosurgery - Soft Tissue and Vascular Injuries Neurosurgery - Soft Tissue and Vascular Injuries Neurosurgery - Soft Tissue and Vascular Injuries Neurosurgery - Soft Tissue and Vascular Injuries Neurosurgery - Soft Tissue and Vascular Injuries Neurosurgery - Soft Tissue and Vascular Injuries Neurosurgery Ep ilepsy Surgery Neurosurgery Ep ilepsy Surgery Neurosurgery Ep ilepsy Surgery
484 485 486 487 488 489 490 491 492 493 494
Co mbined trans oral surgery and CV Junction fusion Inv - MRI,X-Ray cerv ical spine Post procedure evidence of Clin ical photograph C.V. Junction fusion Inv - MRI,X-Ray cerv ical spine Post procedure evidence of Clinical photograph Endoscopy procedures Inv - MRI Post procedure evidence of Endoscopy picture De-co mpressive Cran iotomy(Non Trau matic) Inv - Post procedure evidence of Clin ical photograph Intra-Cerebral Hematoma evacuation Inv - M RI Post procedure evidence of Clin ical photograph Endoscopic Third Ventriculostomy - Post procedure evidence of Clin ical photograph Anterior discectomy & bone grafting Inv - M RI Post procedure evidence of X-Ray Discectomy with Implants Inv -MRI Post procedure evidence of X-Ray Corpectomy for Spinal Fixat ion Inv - M RI Post procedure evidence of X-Ray Spinal Fixat ion Rods and Plates, Artificial d iscs Inv -MRI Post procedure evidence of X-Ray Syringo myelia Inv -M RI Post procedure evidence of Clinical photograph Repair of Brachial plexus injury Inv - M RI Post procedure evidence of Clin ical photograph Cerv ical Sy mpathectomy Inv -EM G,Nerve conduction MRI Post procedure evidence of Clin ical photograph Lu mbar sympathectomy Inv - EM G,Nerve conduction MRI Colo r doppler Post procedure evidence of Clin ical photograph/Biopsy Deco mpression/Excision of Optic nerve lesions Inv - M RI Post procedure evidence of Clinical photograph Peripheral nerve injury repair Inv -EM G,Nerve conduction Post procedure evidence of Clin ical photograph Proptosis Inv - MRI Post procedure evidence of Clin ical photograph Temporal Lobectomy Inv - M RI,Video EEG, Psychologic assessment Post procedure evidence of Clinical photograph Lesionectomy type 1 Inv -M RI,Video EEG, Psychologic assessment Post procedure evidence of Clinical photograph Lesionectomy type 2 Inv -M RI,Video EEG, Psychologic assessment Post procedure evidence of Clinical photograph
20000 65000 50000 60000 30000 40000 65000 70000 85000 65000 60000
495
50000
496
50000
497
65000
498 499
50000 60000
500
90000
501
150000
502
150000
~ 93 ~

Indicativ e Rate &
503
Neurosurgery Ep ilepsy Surgery Neurosurgery Trigeminal Neuralgia Neurosurgery Trigeminal Neuralgia Neurosurgery Management of Aneurysms Neurosurgery Management of Aneurysms Surgical Oncology Head and neck Surgical Oncology Head and neck Surgical Oncology Head and neck Surgical Oncology Head and neck Surgical Oncology Head and neck Surgical Oncology Head and neck Surgical Oncology Head and neck Surgical Oncology Head and neck Surgical Oncology Head and neck Surgical Oncology Head and neck Surgical Oncology Ca.Eye/ Maxilla /Para Nasal Sinus Surgical Oncology Ca.Eye/ Maxilla /Para Nasal Sinus
Temporal lobectomy plus Depth Electrodes Inv MRI,Video EEG, Psychologic assessment Post procedure evidence of Clin ical photograph/X-Ray Radiofrequency ablation Inv - EM G,Nerve conduction Post procedure evidence of Clinical photograph Micro vascular decompression Inv -EM G,Nerve conduction Post procedure evidence of Clinical photograph Embo lizat ion Inv - M RI,Angiogram Post procedure evidence of Clin ical photograph Cost of each coil Inv - M RI,Angiogram Post procedure evidence of Clin ical photograph Co mposite resection & Reconstruction Inv Clin ical photograph, X-Ray,USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Wide excision Inv - Clin ical photograph, XRay,USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Nech dissection any type Inv - Clin ical photograph, X-Ray,USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Hemiglossectomy Inv - Clinical photograph, XRay,USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Maxillectomy any type Inv -Clinical photograph, X-Ray,USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Thyroidectomy any type Inv - Clinical photograph, X-Ray,USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Parotidectomy any type Inv - Clin ical photograph, X-Ray,USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Laryngectomy any type Inv - Clin ical photograph, X-Ray,USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Laryngo pharyngo oesophagectomy Inv - Clin ical photograph, X-Ray,USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Hemimandibulecto my Inv - Clinical photograph, X-Ray,USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Orbital exenteration Inv - CT Post procedure evidence of Clin ical photograph, Biopsy Maxillectomy + Orbital exenteration Inv - CT Post procedure evidence of Clin ical photograph, Biopsy
504 505
30000 60000
506
50000
507 508
30000 60000
509
25000
510
25000
511 512
15000 25000
513
20000
514 515
20000 40000
516
75000
517 518
25000 25000
519
35000
~ 94 ~

Indicativ e Rate &
520
521 522
Surgical Oncology Ca.Eye/ Maxilla /Para Nasal Sinus Surgical Oncology Ca.Eye/ Maxilla /Para Nasal Sinus Surgical Oncology Nasopharynx Surgical Oncology Ca.Soft Palate Surgical Oncology Ca.ear Surgical Oncology Ca.ear Surgical Oncology Ca.ear Surgical Oncology Ca.ear Surgical Oncology
523 524 525
Maxillectomy + In fratemporal Fossa clearance Inv - CT Post procedure evidence of Clinical photograph, Biopsy Cran io Facial Resection Inv - CT,M RI Post procedure evidence of Clin ical photograph, Biopsy Resection of Nasopharyngeal Tu mour Inv CT,M RI Post procedure evidence of Clin ical photograph, Biopsy Palatectomy Any type Inv - CT Post procedure evidence of Clin ical photograph, Biopsy Sleeve Resection Inv - CT Post procedure evidence of Clin ical photograph, Biopsy Lateral Temporal bone resection Inv - CT,M RI Post procedure evidence of Clin ical photograph, Biopsy Subtotal Temporal bone resection Inv - CT,M RI Post procedure evidence of Clin ical photograph, Biopsy Total Temporal bone resection Inv - CT,MRI Post procedure evidence of Clin ical photograph, Biopsy Submandibular Gland Excision Inv - Clinical photograph, FNAC Post procedure evidence of Clin ical photograph, Biopsy Tracheal Resection Inv - CT,Brochscopy Post procedure evidence of Clin ical photograph, Biopsy Sternotomy + Superior Mediastinal Dissection Inv - CT Post procedure evidence of Clinical photograph, Biopsy Tracheal Resection Inv - CT,Brochoscopy Post procedure evidence of Clin ical photograph, Biopsy Parathyroidectomy Inv - CT,Nuclear scan, S.PTH Post procedure evidence of Clin ical photograph, Biopsy Small bowel resection Inv - CT,Bariu m follow through Post procedure evidence of Clin ical photograph, Biopsy Closure of Ileostomy Inv - Colonoscopy Post procedure evidence of Clin ical photograph Closure of Co lostomy Inv -Colonoscopy Post procedure evidence of Clin ical photograph Abdomino Perineal Resection (APR) + Sacrectomy Inv - CT,BM FT,Co lonoscopy,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Posterior Exenteration Inv CT,BM FT,Colonoscopy,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Total Exenteration Inv CT,BM FT,Colonoscopy,Biopsy Post procedure evidence of Clin ical photograph, Biopsy
70000 50000
30000 25000 30000
526 527
50000 60000
528
20000
529 530
Surgical Oncology Ca.Thyroid Surgical Oncology Ca Trachea Surgical Oncology Ca Trachea Surgical Oncology Ca Parathyroid Surgical Oncology Ca GIT Surgical Oncology Ca GIT Surgical Oncology Ca GIT Surgical Oncology Ca Rectu m
52000 45000
531
40000
532 533
30000 40000
534 535 536
20000 20000 50000
537 538
Surgical Oncology Ca Rectu m Surgical Oncology Ca Rectu m
50000 75000
~ 95 ~

Indicativ e Rate &
539
Surgical Oncology Ca GIT Surgical Oncology Ca GIT Surgical Oncology Ca GIT Surgical Oncology Ca GIT Surgical Oncology Ca GIT Surgical Oncology Ca GIT Surgical Oncology Ca GIT Surgical Oncology Ca GIT Surgical Oncology Ca Gall Bladder Surgical Oncology Ca Spleen Surgical Oncology Ca Retroperitoneal Tumors Surgical Oncology Ca Abdominal wall tumour Surgical Oncology Ca Abdominal wall tumour Surgical Oncology Gynec Surgical Oncology Gynec Surgical Oncology Gynec Surgical Oncology Gynec Surgical Oncology Ca Cerv ix
540 541
542
543 544
545
546 547 548 549
Oesophagectomy any type Inv USG,CTBiopsy,Endoscopy Post procedure evidence of Clin ical photograph, Biopsy/USG Gastrectomy any type Inv USG,CTBiopsy,Endoscopy Post procedure evidence of Clin ical photograph, Biopsy/USG Colecto my any type Inv USG,CTBiopsy,Endoscopy Post procedure evidence of Clin ical photograph, Biopsy/USG Anterior resection Inv USG,CTBiopsy,Endoscopy Post procedure evidence of Clin ical photograph, Biopsy/USG Abdominoperineal resection Inv USG,CTBiopsy,Endoscopy Post procedure evidence of Clin ical photograph, Biopsy/USG Whipples any type Inv USG,CTBiopsy,Endoscopy Post procedure evidence of Clin ical photograph, Biopsy/USG Tripple bypass Inv -USG,CTBiopsy,Endoscopy Post procedure evidence of Clin ical photograph, Biopsy/USG Other Bypasses-Pancreas Inv USG,CTBiopsy,Endoscopy Post procedure evidence of Clin ical photograph, Biopsy/USG Radica l Cholecystectomy Inv -CT Post procedure evidence of Clin ical photograph, Biopsy Splenectomy Inv - CT Post procedure evidence of Clin ical photograph, Biopsy Resection of Retroperitoneal Tu mours Inv CT,FNA C Post procedure evidence of Clinical photograph, Biopsy Abdominal wall tumour Resection Inv CT,FNA C Post procedure evidence of Clinical photograph, Biopsy Resection with reconstruction Inv - CT,FNAC Post procedure evidence of Clin ical photograph, Biopsy Bilateral pelvic ly mph Node Dissection(BPLND) Inv - CT Post procedure evidence of Clinical photograph, Biopsy Radical Trachelectomy Inv - CT Post procedure evidence of Clin ical photograph, Biopsy Radical vaginectomy Inv - CT,Biopsy Post procedure evidence of Clin ical photograph, Biopsy Radical vaginectomy + Reconstruction Inv CT,Biopsy Post procedure evidence of Clinical photograph, Biopsy Radical Hysterectomy +Bilateral Pelvic Ly mph Node Dissection (BPLND) + Bilateral Salpingo Ophorectomy (BSO) / Ovarian transposition Inv PAP Smear, Biopsy, CT Post procedure evidence of Clinical photograph, Biopsy
40000 40000
50000
40000 75000
25000
25000 60000 35000 45000
550
35000
551 552
45000 25000
553 554
40000 40000
555
45000
556
45000
~ 96 ~

Indicativ e Rate &
557
Surgical Oncology Ca Cerv ix Surgical Oncology Ca Cerv ix Surgical Oncology Ca Cerv ix Surgical Oncology Ca Cerv ix Surgical Oncology Ca Endo metriu m
558 559
560
561
Anterior Exenteration Inv - PAP Smear, Biopsy, CT Post procedure evidence of Clinical photograph, Biopsy Posterior Exenteration Inv -PAP Smear, Biopsy, CT Post procedure evidence of Clin ical photograph, Biopsy Total Pelvic Exenteration Inv - PAP Smear, Biopsy, CT Post procedure evidence of Clin ical photograph, Biopsy Supra Levator Exenteration Inv -PAP Smear, Biopsy, CT Post procedure evidence of Clinical photograph, Biopsy Total Abdominal Hysterectomy(TA H) + Bilateral Salpingo ophorectomy (BSO) + Bilateral pelvic ly mph Node Dissection (BPLND) + Omentectomy Inv - Endometrial Biopsy, CT Post procedure evidence of Clin ical photograph, Biopsy Chest wall resection Inv - CT Chest, Bone scan Post procedure evidence of Clin ical photograph, Biopsy Chest wall resection + Reconstruction Inv - CT Chest, Bone scan Post procedure evidence of Clin ical photograph, Biopsy Without prosthesis Inv - CT Local part, CT Chest, MRI, Bone scan Post procedure evidence of Clin ical photograph, Biopsy With Custom made Prosthesis Inv - CT Local part, CT Chest, MRI, Bone scan Post procedure evidence of Clin ical photograph, Biopsy With Modular Prosthesis Inv - CT Local part, CT Chest, MRI, Bone scan Post procedure evidence of Clinical photograph, Biopsy Forequarter amputation Inv - CT Chest Post procedure evidence of Clin ical photograph/X-Ray Biopsy Hemipelvectomy Inv - CT,M RI Pelvis, CT Chest Post procedure evidence of Clin ical photograph/X-Ray Biopsy Internal he mipelvectomy Inv - CT,M RI Pelvis, CT Chest Post procedure evidence of Clin ical photograph/X-Ray Biopsy Curettage & bone cement Inv - CT,M RI Post procedure evidence of Clin ical photograph/X-Ray Biopsy Bone resection Inv - CT,M RI Post procedure evidence of Clin ical photograph/X-Ray Biopsy Shoulder gird le resection Inv - CT,MRI,Bone scan Post procedure evidence of Clin ical photograph/X-Ray Biopsy Sacral resection Inv - CT,M RI Post procedure evidence of Clin ical photograph/X-Ray Biopsy
50000 75000
70000
35000
562
563
Surgical Oncology Soft tissue /Bone tumours . Chest wall Surgical Oncology Soft tissue /Bone tumours . Chest wall Surgical Oncology Limb Salvage Surgery Surgical Oncology Limb Salvage Surgery Surgical Oncology Limb Salvage Surgery Surgical Oncology Limb Salvage Surgery Surgical Oncology Limb Salvage Surgery Surgical Oncology Limb Salvage Surgery Surgical Oncology Limb Salvage Surgery Surgical Oncology Limb Salvage Surgery Surgical Oncology Limb Salvage Surgery Surgical Oncology Limb Salvage Surgery
20000
30000
564
40000
565
50000
566
75000
567 568
40000 55000
569
65000
570 571
30000 30000
572
40000
573
60000
~ 97 ~

Indicativ e Rate &
574
Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Genitourinary Surgical Oncology Testis Cancer
575
Partial Nephrectomy Inv - CT,Isotope renogram Post procedure evidence of Clin ical photograph, Biopsy Nephroureterectomy for Transitional Cell Carcinima of renal pelvis Inv - CT Post procedure evidence of Clin ical photograph, Biopsy Radical nephrectomy Inv USG,KUB,IVP,CT,Biopsy Post procedure evidence of Clin ical photograph, Biopsy/USG Emasculation Inv - USG,,Biopsy Post procedure evidence of Clin ical photograph, Biopsy/USG Radical cystectomy Inv USG,KUB,IVP,CT,Biopsy Post procedure evidence of Clin ical photograph, Biopsy/USG Other cystectomies Inv USG,KUB,IVP,CT,Biopsy Post procedure evidence of Clin ical photograph, Biopsy/USG Total penectomy Inv -Clin ical Photograph Post procedure evidence of Clin ical photograph, Biopsy/USG Partial penectomy Inv - Clin ical Photograph Post procedure evidence of Clin ical photograph, Biopsy/USG Inguinal block dissection one side Inv - Clinical Photograph Biopsy Post procedure evidence of Clin ical photograph, Biopsy/USG Radical prostatectomy Inv - USG,KUB,CT Post procedure evidence of Clin ical photograph, Biopsy/USG High orchidecto my Inv - USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy/USG Bilateral orch idectomy Inv - USG,Biopsy Post procedure evidence of Clin ical photograph, Biopsy/USG Retro Peritoneal Ly mph Node Dissection(RPLND) (for Residual Disease) Inv CT Chest, CT Abdomen pelvis, Tu mour markers Post procedure evidence of Clin ical photograph,biopsy Adrenalectomy Inv - CT,M RI,Urinary hormones Post procedure evidence of Clin ical photograph,biopsy Urinary diversion Inv - Post procedure evidence of Clin ical photograph,biopsy Retro Peritoneal Ly mph Node Dissection RPLND as part of staging Inv - CT Post procedure evidence of Clin ical photograph,biopsy Anterior Exenteration Inv - Cystoscopy, Biopsy, CT Post procedure evidence of Clinical photograph, Biopsy Total Exenteration Inv - Cystoscopy, Biopsy, CT Post procedure evidence of Clin ical photograph, Biopsy
50000
576
40000
577 578
30000 60000
579
40000
580 581
25000 15000
582
15000
583 584
60000 15000
585
10000
586
60000
587
Surgical Oncology Testis Cancer Surgical Oncology Testis Cancer Surgical Oncology Testis Cancer Surgical Oncology Ca Urinary Bladder Surgical Oncology Ca Urinary Bladder
45000
588 589
40000 20000
590 591
60000 75000
~ 98 ~

Indicativ e Rate &
592
Surgical Oncology Ca Urinary Bladder Surgical Oncology Thorax, Mediastinu m Surgical Oncology Lung Surgical Oncology Lung Surgical Oncology Lung Surgical Oncology Oesophagus Surgical Oncology Oesophagus Surgical Oncology Palliat ive Surgeries Surgical Oncology Palliat ive Surgeries Surgical Oncology Palliat ive Surgeries Surgical Oncology Palliat ive Surgeries Surgical Oncology Palliat ive Surgeries Surgical Oncology Palliat ive Surgeries Surgical Oncology Palliat ive Surgeries Surgical Oncology Palliat ive Surgeries Surgical Oncology Palliat ive Surgeries Surgical Oncology Palliat ive Surgeries Surgical Oncology Reconstruction Surgical Oncology Reconstruction Surgical Oncology Gynecology
593 594 595 596 597
598
599 600 601 602 603 604 605 606
Bilateral pelvic ly mph Node Dissection(BPLND) Inv - CT Post procedure evidence of Clinical photograph, Biopsy Mediastinal tumour resection Inv - CT Post procedure evidence of Clin ical photograph, Biopsy Lung metastatectomy . Solitary Inv - CT Post procedure evidence of X-Ray , Biopsy Lung metastatectomy . Mult iple Inv - CT Post procedure evidence of X-Ray , Biopsy Sleeve resection of Lung cancer.Inv - CT Post procedure evidence of X-Ray , Biopsy Oesophagectomy with Two field Ly mphadenectomy Inv - UGI, Endoscopy, Biopsy, CT Post procedure evidence of Clin ical photograph, Biopsy Oesophagectomy with Three field Ly mphadenectomy Inv - UGI, Endoscopy, Biopsy, CT Post procedure evidence of Clin ical photograph, Biopsy Tracheostomy Inv - Clinical Photograph Post procedure evidence of Clin ical photograph Substernal bypass Inv - Clinical Photograph Post procedure evidence of Clin ical photograph, Biopsy Gastrostomy Inv - Clinical Photograph Post procedure evidence of Clin ical photograph Jejunostomy Inv - Clinical Photograph Post procedure evidence of Clin ical photograph Ileostomy Inv - Clinical Photograph Post procedure evidence of Clin ical photograph Colostomy Inv - Clinical Photograph Post procedure evidence of Clin ical photograph Suprapubic Cystostomy Inv - Clin ical Photograph Post procedure evidence of Clin ical photograph Intercostal Drainage(ICD) Inv - Clinical Photograph Post procedure evidence of Clin ical photograph Gastro Jejunostomy Inv - Clinical Photograph Post procedure evidence of Clin ical photograph, Biopsy Ileotransverse Colostomy Inv - Clin ical Photograph Post procedure evidence of Clin ical photograph, Biopsy Myocutaneous / cutaneous flap Inv -Clinical Photograph Post procedure evidence of Clinical photograph Micro vascular reconstruction Inv - Clinical Photograph Post procedure evidence of Clinical photograph Hysterectomy Inv - USG/ CT, Biopsy /Endoscopy Post procedure evidence of Clin ical photograph,Biopsy/USG
50000 50000 60000 90000 90000
100000
5000 35000 20000 20000 20000 20000 10000 3000
607 608
35000 50000
609
25000
610 611
45000 25000
~ 99 ~

Indicativ e Rate &
612
Surgical Oncology Gynecology Surgical Oncology Gynecology Surgical Oncology Gynecology Surgical Oncology Gynecology Surgical Oncology Gynecology Surgical Oncology Breast Surgical Oncology Breast Surgical Oncology Breast Surgical Oncology Breast Surgical Oncology Breast Surgical Oncology Breast Surgical Oncology Skin Tu mours Surgical Oncology Skin Tu mours Surgical Oncology Skin Tu mours Surgical Oncology Soft tissue /Bone tumours . Surgical Oncology Soft tissue /Bone tumours . Surgical Oncology Soft tissue /Bone tumours . Surgical Oncology Lung
613 614
615
616 617
Radical Hysterectomy Inv - USG/CT / Endoscopy, Biopsy Post procedure evidence of Clinical photograph,Biopsy/USG Surgery for ca Ovary early stage Inv - USG/ CT /Endoscopy, Biopsy Post procedure evidence of Clin ical photograph,Biopsy/USG Surgery for ca Ovary Advance stage Inv USG/ CT / Endoscopy, Biopsy Post procedure evidence of Clin ical photograph,Biopsy/USG Vu lvectomy Inv - USG/CT / Endoscopy, Biopsy Post procedure evidence of Clin ical photograph,Biopsy/USG Salpino oophorectomy Inv - USG/ CT / Endoscopy, Biopsy Post procedure evidence of Clinical photograph,Biopsy/USG Mastectomy any type Inv - Clin ical photograph, Mammography, Biopsy Post procedure evidence of Clinical photograph,Biopsy Axillary dissection Inv - Clinical photograph, Biopsy Post procedure evidence of Clinical photograph,Biopsy Wide excision Inv - Clin ical photograph, Biopsy Post procedure evidence of Clinical photograph,Biopsy Lu mpectomy Inv - Clinical photograph, Biopsy Post procedure evidence of Clinical photograph,Biopsy Breast reconstruction Inv - Clin ical photograph, Biopsy Post procedure evidence of Clinical photograph,Biopsy Chest wall resection Inv -Clin ical photograph, Biopsy Post procedure evidence of Clinical photograph,Biopsy Skin tu mours wide excision Inv - Clinical photograph, Biopsy Post procedure evidence of Clin ical photograph,Biopsy Skin tu mours wide excision + Reconstruction Inv - Clinical photograph, Biopsy Post procedure evidence of Clinical photograph,Biopsy Skin tu mours amputation Inv - Clin ical photograph, Biopsy Post procedure evidence of Clin ical photograph,Biopsy Wide excision Inv - Clinical photograph, Biopsy Post procedure evidence of Clinical photograph,Biopsy Wide excision + reconstruction Inv -Clinical photograph, Biopsy Post procedure evidence of Clin ical photograph,Biopsy Amputation Inv - Clinical photograph, Biopsy Post procedure evidence of Clinical photograph,Biopsy Lung cancer pnumenectomy Inv - XRay/CT,Biopsy Post procedure evidence of Clin ical photograph,Biopsy/X-Ray
25000 40000
15000
25000 25000
618
15000
619 620
5000 3000
621
25000
622 623
20000 10000
624
20000
625 626
20000 15000
627
25000
628 629
20000 50000
~ 100 ~
Signature & s tamp of Ins urance Agency

Indicativ e Rate &
630
Surgical Oncology Lung Surgical Oncology Lung Surgical Oncology bronchoplural fistula Surgical Oncology bronchoplural fistula Surgical Oncology bronchoplural fistula
631 632
633
Lung cancer Lobectomy Inv - X-Ray/CT,Biopsy Post procedure evidence of Clin ical photograph,Biopsy/X-Ray Lung Cancer Decort ication Inv - XRay/CT,Biopsy Post procedure evidence of Clin ical photograph,Biopsy/X-Ray Surgical correct ion of bronchoplural fistula Thoracoplasty Inv - X-Ray/CT,Biopsy Post procedure evidence of Clin ical photograph,Biopsy/X-Ray Surgical correct ion of bronchoplural fistula . Myoplasty Inv -X-Ray/CT,Biopsy Post procedure evidence of Clin ical photograph,Biopsy/X-Ray Surgical correct ion of bronchoplural fistula Trans plural BPF closure Inv - X-Ray/CT,Biopsy Post procedure evidence of Clin ical photograph,Biopsy/X-Ray Marginal Mandibulecto my Inv - Orthopantogram Post procedure evidence of Clin ical photograph,Biopsy Segmental Mandibulectomy Inv Orthopantogram/ CT Post procedure evidence of Clin ical photograph,Biopsy Total glossectomy + Reconstruction Inv CT,Biopsy Post procedure evidence of Clinical photograph,Biopsy Full thickness Buccal mucosal resection & Reconstruction Inv - Biopsy Post procedure evidence of Clin ical photograph,Biopsy Adriamycin/Cyclophosphamide (A C) Inv Clin ical photograph, Mammography, Biopsy Post procedure evidence of Clin ical photograph 5- Flurouracil A-C (FA C) Inv - Clinical photograph, Mammography, Biopsy Post procedure evidence of Clin ical photograph AC (A C Then T) Inv - Clinical photograph, Mammography, Biopsy Post procedure evidence of Clinical photograph Paclitaxel Inv - Clin ical photograph, Mammography, Biopsy Post procedure evidence of Clinical photograph Cyclophosphamide / Methotraxate / 5Flurouracil (CM F) Inv - Clinical photograph, Mammography, Biopsy Post procedure evidence of Clinical photograph Tamo xifen Tabs Inv - Clin ical photograph, Mammography, Biopsy Post procedure evidence of Clinical photograph Aromatase inhibitors Inv - Clinical photograph, Mammography, Biopsy Post procedure evidence of Clinical photograph
50000 50000
50000
634
50000
635
Surgical Oncology Oral cavity Surgical Oncology Oral cavity Surgical Oncology Oral cavity Surgical Oncology Oral cavity Medical Oncology Breast Medical Oncology Breast Medical Oncology Breast Medical Oncology Breast Medical Oncology Breast
25000
636 637
25000 40000
638
50000
639 640
3000 3100
641
3000
642 643
9500 1500
644
Medical Oncology Breast Medical Oncology Breast
85 per month 835 per month
645
~ 101 ~

Indicativ e Rate &
646
Medical Oncology Urinary Bladder Medical Oncology Urinary Bladder Medical Oncology Non small cell Lung cancer Medical OncologyOesophagu s Medical Oncology Stomach Medical Oncology Colon Rectum Medical Oncology Colon Rectum
647 648
649
Bladder cancer weekly Cisplastin Inv USG,Biosy Post procedure evidence of Clinical photograph Methotraxate Vinblastin Adriamycin Cyclophosphamide (M VA C) Inv -USG/CT,Biosy Post procedure evidence of Clin ical photograph Cisplastin/Etoposide (IIIB) Inv - X-Ray/CT Scan,Biopsy Post procedure evidence of Clinical photograph Cisplastin- 5FU Inv - Endoscopy/CT Scan, Biopsy Post procedure evidence of Clin ical photograph 5-FU Leucovorin (M CDONA LD Regimen) Inv Endoscopy/CT Scan, Biopsy Post procedure evidence of Clin ical photograph Monthly 5-FU Inv - Endoscopy/CT Scan, Biopsy Post procedure evidence of Clin ical photograph 5- Flurouracil-Oxaliplastin Leucovorin (Fo lfo x) (Stage III only) Inv - Endoscopy/CT Scan, Biopsy Post procedure evidence of Clin ical photograph Cisplastin/Adriamycin Inv - X-Ray/CT Scan, Biopsy Post procedure evidence of Clinical photograph Adriamycin Bleo mycin Vinblastin Dacarbazine (ABVD) Inv - Biopsy Post procedure evidence of Clin ical photograph Cyclophosphamide Adriamycin Vincristin Prdnisone (CHOP) Inv - Biopsy Post procedure evidence of Clin ical photograph Vincristin, Adriamycin,De xamethasone (VAD) Inv - Hematology Post procedure evidence of Clin ical photograph Thalido mide+Dexamethasone(oral) Inv Hematology Post procedure evidence of Clinical photograph Melphalan Prednisone oral Inv - Hematology Post procedure evidence of Clin ical photograph SIOP/NWTS Regimen (Stages I III) Inv USG/ CT,Biopsy Post procedure evidence of Clin ical photograph Cisplastin Adriamycin Inv - USG/ CT,Biopsy Post procedure evidence of Clin ical photograph Cerv ical cancer weekly Cisplastin Inv USG,Biopsy Post procedure evidence of Clinical photograph Variabe regimen Inv - Hematology Post procedure evidence of Clin ical photograph Variabe reg imen Inv - CT,Biopsy Post procedure evidence of Clin ical photograph
5000 7000
5000
650 651 652
5000 4000 10000
653
654
655
Medical Oncology Bone tumors/Osteosarcom a Medical Oncology Lu mpho ma, Hoggkin's Medical Oncology Lu mpho ma NHL Medical Oncology Multiple Myelo ma Medical Oncology Multiple Myelo ma Medical Oncology Multiple Myelo ma Medical Oncology Wilm's Tu mor Medical Oncology Hepatoblastoma Operable Medical Oncology Cerv ix Medical Oncology Childhood B-Cell Ly mpho mas Medical Oncology Neuroblastoma Stage I III
20000
4000
3500
656
4000
657 658 659 660
3000 1500 7000 per month 15000
661
2000
662 663
up to 12000 up to 10000
~ 102 ~

Indicativ e Rate &
664 665 666
Medical Oncology Retinoblastoma Medical Oncology Histocytosis Medical Oncology Rhabdomyosarcoma Medical Oncology Ewing's Sarco ma Medical Oncology Acute Myeloid Leukemia Medical Oncology Acute Myeloid Leukemia Medical Oncology Acute Myeloid Leukemia Medical Oncology Acute Lymphatic Leukemia Medical Oncology Acute Lymphatic Leukemia Medical Oncology Acute Lymphatic Leukemia Medical Oncology For Un listed regimen Medical Oncology Terminally ill Medical Oncology Vu lval cancer Medical Oncology Colo Rectal Cancer Stage 2 and 3 Medical Oncology Multiple Myelo ma
Carbo/Etoposide/Vincristin Inv - Biopsy Post procedure evidence of Clin ical photograph Variabe reg imen Inv - Hematology, Biopsy Post procedure evidence of Clin ical photograph Vincristin-Actinomycin-Cyclophosphamide (VA CTC) Based chemo Inv -Biopsy Post procedure evidence of Clin ical photograph Variabe regimen Inv - X-Ray/ CT Scan, Biopsy Post procedure evidence of Clin ical photograph Induction phase Inv - Hematology Post procedure evidence of Clin ical photograph Co msolidation phase Inv - Hematology Post procedure evidence of Clin ical photograph Maintenance phase Inv - Hematology Post procedure evidence of Clin ical photograph Induction 1st and 2 nd months Inv - Hematology Post procedure evidence of Clin ical photograph Induction 3RD, 4TH, 5TH Inv - Hematology Post procedure evidence of Clin ical photograph Maintenance phase Inv - Hematology Post procedure evidence of Clin ical photograph Palliat ive Chemotherapy Inv - USG/ CT,Biopsy Post procedure evidence of Clin ical photograph Palliat ive and supportive therapy Inv USG/ CT,Biopsy Post procedure evidence of Clin ical photograph Cisplastin/5-FU Inv - Clinical Photograph, Biopsy Post procedure evidence of Clin ical photograph XELOX along with Adjuvant chemotherapy of AS-I Inv - CT Abdomen,pelvis, Tissue biopsy, photograph Post procedure evidence of USG/ CT/ Biopsy/Biochemical investigations Zoledronic acid along with Adjuvant Chemotherapy of AS-I Inv - SIEP,Urine fo r Bence Jones protein, Skeltal survey, Bone marrow aspiration, Biopsy, S. Electrolytes, 2D ECHO Post procedure evidence of USG/ CT/ Biopsy/Biochemical investigations 1ST Line iv antibiot ics And other supportive therapy ( third generation cephalosporin, aminoglycoside etc.,) Inv - Blood C.S. Urine C.S., Chest X-Ray, Tissue biopsy Post procedure evidence of USG/CT/Biopsy/Biochemical investigations
Upper ceiling (Rs.) 4000 up to 8000 p m 9000 per month up to 9000 per month up to 60000 up to 40000 3000 per month up to 50000 up to 20000 3000 per month up to 5000per cycle 3000 per month 5000 4000
667
668
669
670 671
672
673 674
675
676 677
678
3000
679
Medical Oncology Febrile Neutropenia FN High Risk 1
9000
~ 103 ~

Indicativ e Rate &
680
Medical Oncology Febrile Neutropenia FN High Risk 2
681 682 683 684
Medical Oncology Vaginal cancer Medical Oncology Ovary Medical Oncology Ovary Germ Cell Tumour Medical Oncology Gestational Trophoblast Ds. Lo w Risk Medical Oncology Gestational Trophoblast Ds. Lo w Risk Medical Oncology Gestational Trophoblast High Risk Medical Oncology Testis Medical Oncology Prostate Radit ion Oncology Cobalt 60 External Beam Rad iotherapy Radit ion Oncology Cobalt60 External Beam Rad iotherapy Radit ion Oncology Cobalt 60 External Beam Rad iotherapy Radit ion Oncology External Bea m Radiotherapy (On Linear Acclerator) Radit ion Oncology External Beam Radiotherapy (On Linear Acclerator) Radit ion Oncology External Beam Radiotherapy (On Linear Acclerator)
2nd line iv antib iotics and other supportive therapy(Carbapenems, Fourth generation cephalosporins, Piperacillin, anti-fungal . azo les etc.,) Inv - Blood C.S. Urine C.S., Chest X-Ray, Tissue biopsy Post procedure evidence of USG/ CT/ Biopsy/Biochemical investigations Cisplastin/5-FU Inv - Clinical photograph, Biopsy Post procedure evidence of Clin ical photograph Carboplastin/ Paclitaxel Inv - USG/ CT,Biopsy Post procedure evidence of Clin ical photograph Bleo mycin-Etoposide-Cisplastin (BEP) Inv USG/ CT,Biopsy Post procedure evidence of Clin ical photograph Weekly Methotrexate Inv - USG/CT,Biopsy Post procedure evidence of Clin ical photograph Actinomycin Inv - USG/ CT,Biopsy Post procedure evidence of Clin ical photograph Etoposide - Methotrexate -Actino mycin / Cyclophosphamide Avincristine (EMA-CO) Inv USG/ CT,Biopsy Post procedure evidence of Clin ical photograph Bleo mycin-Etoposide-Cisplastin (BEP) Inv USG,Biosy Post procedure evidence of Clinical photograph Hormonal Therapy Inv - USG,Biosy Post procedure evidence of Clin ical photograph Radical Treat ment Inv - USG/CT/X-Ray,Biopy Post procedure evidence of Clin ical photograph,RT Treat ment charts Palliat ive Treat ment Inv - USG/ CT/ X-Ray,Biopy Post procedure evidence of Clin ical photograph,RT Treat ment charts Adjuvant Treatment Inv -USG/ CT/X-Ray,Biopy Post procedure evidence of Clin ical photograph,RT Treat ment charts Radical Treat ment with photons Inv - USG/ CT/ XRay,Biopy Post procedure evidence of Clin ical photograph,RT Treat ment charts Palliat ive Treat ment with photons Inv USG/ CT/ X-Ray,Biopy Post procedure evidence of Clinical photograph,RT Treat ment charts Adjuvant Treatment with photons/Electrons Inv USG/ CT/ X-Ray,Biopy Post procedure evidence of Clin ical photograph,RT Treat ment charts
5000 10500 8000 600
685
3000
686
6000
687
8000
688 689
3000 per month 20000
690
10000
691
15000
692
50000
693
20000
694
35000
~ 104 ~

Indicativ e Rate &
695
696 697
698
Radit ion Oncology Brachytherapy Intracavity Radit ion Oncology Brachytherapy Intracavity Radiat ion Oncology Brachytherapy Interstitial Radiat ion Oncology Brachytherapy Interstitial Radiat ion Oncology Specialized Radiat ion Therapy IMRT (Intensity modulated radiotherapy) Radiat ion Oncology S Specialized Radiat ion Therapy 3DCRT(3-D conformat ional radiotherapy) Radiat ion Oncology Specialized Radiat ion Therapy SRS/SRT Radiat ion Oncology Specialized Radiat ion Therapy Rapid A x therapy Radiat ion Oncology Specialized Radiat ion Therapy IMRT With IGRT Plastic Surgery Plastic Surgery Plastic Surgery Plastic Surgery Plastic Surgery Plastic Surgery
A) Intracavitary I. LDR per application Inv USG/ CT/ X-Ray,Biopy Post procedure evidence of A) Intracavitary II. HDR per applicat ion Inv USG/ CT/ X-Ray,Biopy Post procedure evidence of B) Interstitial I. LDR per applicat ion Inv USG/ CT/ X-Ray,Biopy Post procedure evidence of B) Interstitial II. HDR one application and mu ltip le dose fractions Inv -USG/CT/XRay,Biopy Post procedure evidence of Clin ical photograph, RT Treat ment charts Up to 40 fractions in 8 weeks Inv - CT with contrast, Biopsy, MRI Post procedure evidence of USG/ CT/Tu mour marker/ RT Treat ment charts
2500 15000
25000
699
100000
700
Up to 30 fractions in 6 weeks Inv -CT with contrast, Biopsy, MRI Post procedure evidence of USG/ CT/Tu mour marker/ RT Treat ment charts
75000
701
Up to 30 fractions in 6 weeks Inv - CT with contrast, Biopsy, MRI Post procedure evidence of USG/ CT/Tu mour marker/ RT Treat ment charts Up to 40 fractions in 8 weeks Inv - CT with contrast, Biopsy, MRI Post procedure evidence of USG/ CT/Tu mour marker/ RT Treat ment charts Up to 40 fractions in 8 weeks Inv - CT with contrast, Biopsy, MRI Post procedure evidence of USG/ CT/Tu mour marker/ RT Treat ment charts Cleft lip Inv - Clinical Phoptograph Post procedure evidence of Clin ical Phoptograph Cleft Palate Inv - Clin ical Phoptograph Post procedure evidence of Clin ical Phoptograph Velo-Pharyngial Inco mpetence Inv - Endoscopy Post procedure evidence of Clin ical Phoptograph Syndactyly of Hand for each hand Inv - Clin ical Phoptograph Post procedure evidence of Clinical Phoptograph Microtia/Anotia Inv - Clin ical Phoptograph Post procedure evidence of Clin ical Phoptograph TM joint anky losis Inv - Clinical Phoptograph, XRay Post procedure evidence of Clin ical Phoptograph
75000
702
150000
703
150000
704 705 706 707 708 709
10000 15000 15000 15000 30000 40000
~ 105 ~

Indicativ e Rate &
710
Burns 30% to 50%
711
Burns 30% to 50%
712
Burns 30% to 50%
713
Burns 30% to 50%
714
Burns Above 50%
715
Burns Above 50%
Up to -40% With scalds ( conservative) Inv Clin ical Photograph Post procedure evidence of Clin ical Phoptograph Upto-40% Mixed Burns( With surgeries) Inv Clin ical Phoptograph Post procedure evidence of Clin ical Phoptograph Upto-50% with scalds(Conservative) Inv Clin ical Phoptograph Post procedure evidence of Clin ical Phoptograph Up to -50% Mixed Burns( With surgeries) Inv Clin ical Phoptograph Post procedure evidence of Clin ical Phoptograph Up to -60% With scalds ( conservative) Inv Clin ical Phoptograph Post procedure evidence of Clin ical Phoptograph Up to -60% Mixed Burns( With surgeries) Inv Clin ical Phoptograph Post procedure evidence of Clin ical Phoptograph ABOVE 60% M ixed Burns( With surgeries) Inv Clin ical Phoptograph Post procedure evidence of Clin ical Phoptograph Mild Inv - Clin ical Phoptograph Post procedure evidence of Clin ical Phoptograph
50000
60000
70000
80000
100000
716
Burns Above 50%
120000
717
718
719
720 721
Burns Post Burn contracture surgeries for functional improvement (Package including splints pressure garments and Physiotherapy) Burns Post Burn contracture surgeries for functional improvement (Package including splints pressure garments and Physiotherapy) Burns Post Burn contracture surgeries for functional improvement (Package including splints pressure garments and Physiotherapy) Plastic Surgery Plastic Surgery
20000
Moderate Inv -Clin ical Phoptograph Post procedure evidence of Clin ical Phoptograph
30000
Severe Inv - Clinical Phoptograph Post procedure evidence of Clin ical Phoptograph
40000
722 723
Plastic Surgery Plastic Surgery
Hemifacial Microsmia Inv - 3 D CT, M RI Post procedure evidence of Clin ical Phoptograph Leprosy reconstructive surgery Inv - Nerve conduction study Post procedure evidence of Clin ical Phoptograph Nerve and tendon repair + Vascular repair Inv Nerve conduction study, CT Scan Post procedure evidence of Clin ical Phoptograph Ptosis Inv -Clinical photograph Post procedure evidence of Clin ical Phoptograph
50000 20000
30000 25000
~ 106 ~

Indicativ e Rate &
724
Plastic Surgery
725 726 727
Plastic Surgery Plastic Surgery Plastic Surgery
728
Plastic Surgery
729 730
Plastic Surgery Plastic Surgery
731 732 733 734 735 736
Plastic Surgery Plastic Surgery Polytrau ma Orthpedic Trau ma Polytrau ma Orthpedic Trau ma Polytrau ma Orthpedic Trau ma Polytrau ma Neurosurgical trauma consertative Polytrau ma Neurosurgical trauma consertative Polytrau ma Neurosurgical trauma Polytrau ma Chest consertative treatment Polytrau ma Chest consertative treatment Polytrau ma Chest Polytrau ma Abdomen consertative treatment Polytrau ma Abdomen consertative treatment
737 738
Tumour of mandible and maxilla Inv CT/M RI/HPE/Biopsy Post procedure evidence of Clin ical Phoptograph Vaginal atresia Inv - USG Abdomen Post procedure evidence of Clin ical Phoptograph Vascular malformations Inv - Angiogram Post procedure evidence of Clin ical Phoptograph Correct ive Surgery for Congenital deformity of hand (per hand) Inv - X-Ray/CT Scan Post procedure evidence of Clin ical Phoptograph Correct ive Surgery for Cran iosynostosis Inv - 3D CT/M RI Post procedure evidence of Clinical Phoptograph Cup and Bat ears Inv - Clinical photograph Post procedure evidence of Clin ical Phoptograph Flap cover fo r Electrical burns with vitals exposed Inv - Clin ical photograph Post procedure evidence of Clinical Phoptograph Reduction surgery for Filarial ly mphedema Inv Clin ical photograph Post procedure evidence of Clin ical Phoptograph Hemifacial atrophy Inv - 3 D CT, M RI Post procedure evidence of Clin ical Phoptograph Open Reduction and internal fixation of long bone fractures Inv - X-Ray Post procedure evidence of X-Ray Amputation Surgery Inv - X-Ray Post procedure evidence of Clin ical Phoptograph Soft tissue injury Inv - Clinical photograph Post procedure evidence of Clin ical Phoptograph Stay in general ward @RS.500/ Day Inv - XRay/CT Post procedure evidence of Clinical Phoptograph Stay in NEURO ICU@RS.4000/DA Y Inv - XRay/CT Post procedure evidence of Clinical Phoptograph Surgical treat ment (Up to) Inv - X-Ray/CT Post procedure evidence of Clin ical Phoptograph Chest injuries Conservative stay in General ward @RS.500/Day Inv -X-Ray/CT Post procedure evidence of Clin ical Phoptograph Stay in Respiratory ICU ICU@RS.4000/ Day Inv X-Ray/CT Post procedure evidence of Clin ical Phoptograph Surgical treat ment Inv - X-Ray/ CT Post procedure evidence of X-Ray Abdominal inju ries Conservative stay in General ward @RS.500/DA Y Inv - X-Ray/USG/ CT Post procedure evidence of USG Stay in Surg ical ICU@RS.1000/ DA Y Inv - XRay/USG/CT Post procedure evidence of USG
25000 25000 15000
50000
20000 50000
20000 30000 15000 5000 5000 6000
28000 150000
739
3000
740 741 742
20000 50000 3000
743
7000
~ 107 ~

Indicativ e Rate &
744
Polytrau ma Abdomen Polytrau ma Emergency room procedures Polytrau ma Emergency room procedures Orthopedic and facial trauma wound management for compound fractures Orthopedic and facial trauma wound management for compound fractures Orthopedic and facial trauma wound management for compound fractures Orthopedic and facial trauma other s mall bone fractures-Kwiring (to be covered along with other injuries only and not as exclusive procedure) Orthopedic and facial trauma other s mall bone fractures-Kwiring (to be covered along with other injuries only and not as exclusive procedure) Orthopedic and facial trauma Facial injuries Orthopedic and facial trauma Pelv ic bone fracture Hearing aid
745 746
Abdominal inju ries surgical treat ment Inv - XRay/USG/CT Post procedure evidence of USG/ Clinical photograph Tracheostomy Inv - Clinical photograph Post procedure evidence of Clin ical photograph Thoracostomy Inv - Clinical photograph Post procedure evidence of Clin ical photograph Grade I& II Inv - Clin ical photograph,X-Ray Post procedure evidence of Clin ical photograph
3000 3000
747
10000
748
Grade -III Inv -Clinical photograph,X-Ray Post procedure evidence of Clin ical photograph
20000
749
Flap cover surgery for wound in co mpound fracture Inv - Clinical photograph,X-Ray Post procedure evidence of Clin ical photograph Surgery for Patella Fracture (To be covered with other injuries only and not as exclusive procedure) Inv -X-Ray Post procedure evidence of X-Ray
20000
750
5000
751
Small bone fractures K-Wiring (To be covered with other injuries only and not as exclusive procedure) Inv - X-Ray Post procedure evidence of X-Ray
5000
752 753
Facial bone fractures (Facio maxillary in juries) Inv -Clinical photograph,X-Ray Post procedure evidence of Clin ical photograph, X-Ray Surgical correct ion of Pelvic Bone fractures. Inv X-Ray Post procedure evidence of X-Ray Behind the ear analogue hearing aid. Inv Audiometry with post treatment evidence of Clin ical photograph HDP/PP with post treatment evidence of Clin ical photograph Fibre with post treatment evidence of Clin ical photograph Modular with post treatment evidence of Clinical photograph HDP/PP with post treatment evidence of Clin ical photograph
15000 20000
754
10000
755 756 757 758
Prosthesis lower limb Symes Prostheses Prosthesis lower limb Symes Prostheses Prosthesis lower limb Symes Prostheses Prosthesis Below Knee(BK/PTB) Prostheses
1000 1200 1500 1200
~ 108 ~

Indicativ e Rate &
759
760 761 762 763 764
765
766 767
768
769 770
771 772 773 774 775 776 777
778 779
Prosthesis Below Knee(BK/PTB) Prostheses Prosthesis Below Knee(BK/PTB) Prostheses Prosthesis Through Knee Prostheses Prosthesis Through Knee Prostheses Prosthesis Through Knee Prostheses Prosthesis Above Knee(AK) Prostheses Prosthesis Above Knee(AK) Prostheses Prosthesis Above Knee(AK) Prostheses Prosthesis Hip disarticulation prosthesis Prosthesis Hip disarticulation prosthesis Prosthesis Hip disarticulation prosthesis Prosthesis Hip disarticulation prosthesis Prosthesis Upper Limb below elbow Prosthesis Upper Limb below elbow Prosthesis Upper Limb below elbow Prosthesis Upper Limb above elbow Prosthesis Upper Limb above elbow Prosthesis Upper Limb above elbow Prosthesis Upper Limb whole upper limb Prosthesis Upper Limb whole upper limb Prosthesis Upper Limb whole upper limb
Fibre with post treatment evidence of Clin ical photograph Modular with post treatment evidence of Clinical photograph HDP/PP with post treatment evidence of Clin ical photograph Fibre with post treatment evidence of Clin ical photograph Modular with post treatment evidence of Clinical photograph HDP/PP with post treatment evidence of Clin ical photograph Fibre with post treatment evidence of Clin ical photograph Modular with post treatment evidence of Clinical photograph HDP/PP with post treatment evidence of Clin ical photograph Fibre with post treatment evidence of Clin ical photograph Modular with post treatment evidence of Clinical photograph Partial foot prostheses with post treatment evidence of Clin ical photograph HDP/PP with post treatment evidence of Clin ical photograph Fibre with post treatment evidence of Clin ical photograph Modular with post treatment evidence of Clinical photograph HDP/PP with post treatment evidence of Clin ical photograph Fibre with post treatment evidence of Clin ical photograph Modular with post treatment evidence of Clinical photograph HDP/PP with post treatment evidence of Clin ical photograph Fibre with post treatment evidence of Clin ical photograph Modular with post treatment evidence of Clinical photograph
3000 1500 1800 3500 1500
1800
3500 2500
3000
6000 500
1500 1800 3500 1500 2000 4000 1000
1200 1500
~ 109 ~

Indicativ e Rate &
Sr No 780
Category Critical Care
781
Critical Care
782
Critical Care
Disease, stay, Investigations, Post treatment evidence Acute severe asthma with Acute respiratory failure Inv - ABG , Seru m IgE , Spiro metry , clinical photo intubated with ventilator , serum electrolytes 10 days stay with post treatment evidence of ABG and other lab investigations COPD Respiratory Failure (infective exacerbation) Inv - Blood gases , HRCT Chest , ventilator when necessary, clinical photograph, spirometry, seru m electrolytes, 2 D Echo 14 days stay with post treatment evidence of ABG and other lab investigations Acute Bronchitis and Pneumonia with Respiratory failure Inv -clin ical photograph HRCT Chest, ABG, ventilator 10 days stay with post treatment evidence of ABG and other lab investigations ARDS with ventilatory care Inv - HRCT Chest, clin ical photograph,ABG 14 days stay with post treatment evidence of ABG and other lab investigations ARDS with Mult i Organ failu re with ventilatory care Inv - HRCT Chest, clinical photograph,ABG, Sputum CS 14 days stay with post treatment evidence of ABG and other lab investigations ARDS plus DIC (Blood & Blood products) with ventilatory care Inv - HRCT Chest, clin ical photograph,ABG, Sputum CS 14 days stay with post treatment evidence of ABG and other lab investigations OP Poisoning requiring ventilatory assistance Clin ical photo Inv - Renal chemistry Drug/Poison level in blood, Blood gases 1 week stay with post treatment evidence of ABG and other lab investigations Septic Shock(ICU Management) with ventilatory assistance Inv - Blood Culture , Blood gases , Clin ical photo, Renal Chemistry , USG , Urine Culture 14 days stay with post treatment evidence of ABG and other lab investigations
Upper ceiling (Rs.) Cost 45000
70000
Treat ment protocol Asthma Gu ide lines GINA /India, Ventilatory Care According to International Gu ide lines, Ventilatory Care IP 10 days, Inhalers, LA BA, Ventilatory Care Antimicrobial s, MICU, O2, Ventilatory Care Antimicrobial s, MICU, O2, Ventilatory Care Cryo precipitate, FFP, Ventilatory Care MICU, O2, Ventilatory Care, atropine
50000
783
Critical Care
80000
784
Critical Care
100000
785
Critical Care
120000
786
Critical Care
30000
787
Critical Care
50000
788
Critical Care Gen Medicine
789
Thrombocytopenia with bleeding d iathesis Inv Bone Marrow , Leptospira , PT APTT , Parasite F / V , Platelet count , Report and video clip "online"one week stay with post treatment evidence of lab investigations Haemophilia with Inv - Factor VIII / IX , PT APTT Report and video clip "online 1 week stay with post treatment evidence of lab investigations
20000
50000
Antimicrobial s, MICU, O2, Ventilatory Care and other supportive measures IV fluids, PRP, SDPIV - IgIV antimicrobial s IV FPP, Factor VIII / Cryoprecip ita te
~ 110 ~

Indicativ e Rate &
790
Other Coagulation disorders with Von willi brands factor, 1 week stay with with post treatment evidence of lab investigations Chelat ion Therapy for Thalassemia serum Inv Ferritin , Heamatocrit , Heamogram , Peripheral Smear , S.Iron , 5 days stay with post treatment evidence of lab investigations Cerebral Malaria (Falciparu m) Inv - CSF Analysis , Parasite F Test and QBC, 7 days stay with post treatment evidence of clin ical and lab investigations
791
20000
IV FPP, Factor VIII / Cryoprecipatt e Chelat ion Therapy
792
20000
793
TB meningit is Inv - ABG , CT Scan Brain CSF ADA Analysis, 2 weeks stay with post treatment evidence of lab investigations
30000
794
Snake bite requiring ventilator support Inv - 8 hourly ABG seven days , CT Scan brain, Blood sugar 4 hourly 2 weeks stay with post treatment evidence of lab investigations
50000
Blood and Platelet Transfusion, IV antibiotics, IV fluids, Mefloquine, IV quin ine or IV artesunate, Paracetamol, Ventilat iory Support Anticonvulsa nts (Midazolam or Lorazepam, Phenobarbito ne or Phenytoin), Antitubercula r therapy, IV Mannitol, IV antibiotics, IV dexamethaso ne and oral steroids, IV flu ids, Mechanical Ventilatory support, Naso gastric feeds, Paracetamol Antisnake Venom, IV flu ids, Inj.Antibiotic s, Inotropes(Do butamine, Dopamine, Adrenaline, Noradrenalin e), Mechanical Ventilat ion, oxygen
~ 111 ~

Indicativ e Rate &
795
Scorpion Sting requiring ventilator support Inv Eight hourly ABG for 7days,Blood sugar 8 hourly ECH, ECG, CVP Monitoring 2 weeks stay with post treatment evidence of lab investigations
796
Metabolic Co ma requiring Ventilatory Support Inv - ABG , Arterial Blood Pressure , Blood Sugar , Blood Urea , CVP monitoring , ECG , Echo , S.Creatin inine , Thyroid Profile, 2 weeks stay with post treatment evidence of lab investigations
30000
797
Infectious diseases
Tetanus severe Inv - A BG, swab for culture sensitivity 3 weeks stay with post treatment evidence of clinical photograph Diphtheria Co mp licated Inv - ECG-5 times , Throat swab for c/s-3 times , Urine for ketone bodies clinical photograph 4 weeks stay with post treatment evidence of and lab investigations Cryptococcal Meningitis Inv - investigation of cryprococcal antigen, treatment of 2 weeks stay with post treatment evidence of lab investigations Term baby with culture positive sepsis - Non ventilated Hyperbilirub inemia Inv - Blood culture, CRP, Seru m bilirubin, CSF Analys is, 14 days stay with post treatment evidence of clinical improvement and lab investigations
20000
Antiscorption Venom, IV flu ids, Antibiotics, prazocin, Mechanical Ventilat ion, Oxygen and other treatment such as SNP drip etc. Inotropes IV antibiotics, IV fluids, Inj.M idazo la m in fusion, Mechanical Ventilat ion, Oxygen, Sodiu m Nitroprusside Medical, Ventilator, tracheostomy Medical, Tracheostom y, ventilator Amphotericin B +Fluconazole 25 % dextrose, Calciu m gluconate, Fluconazole, IV antib iotics -Meropenem , Maintenance IV Fluids Isolyte P, Nasogastric tube feeds, Phototherapy, Tobramycin 80mg
798
Infectious diseases
25000
799
Infectious diseases
20000
800
Paediatrics Neonatal
25000
~ 112 ~

Indicativ e Rate &
801
Pediatrics Neonatal
30 to 32 weeks preterm Severe Hyaline memb rane disease Clin ical sepsis Patent ductus arteriosus Medical management Mechanical ventilat ion Hyperbilirubinemia Inv - 2D ECHO , Neurosonogram , Blood culture, CRP, A BG, 8 weeks stay with post treatment evidence of clin ical imp rovement and lab investigations
802
Pediatrics Neonatal
<30 weeks preterm Severe Hyaline memb rane disease Clin ical/ Culture positive sepsis Patent ductus arteriosus - Medical management Mechanical ventilation Hyperbilirubinemia Inv 2D ECHO , Neurosonogram, Blood culture, CRP, ABG 8 weeks stay with post treatment evidence of clinical improvement and lab investigations
90000
25 % dextrose, Calciu m gluconate, Dobutamine, Dopamine, FFP, Frusemide, Heparin, IV antibiotics (Meropenem - , Tobramycin Fluconazole), Maintenance IV Fluids , Mechanical ventilation, Midazolam, Nasogastric tube feeds, PRBC, FFP, PRP, PhototherapyUmbilical venous and arterial lines, Supplemental Oxygen, Surfactant therapy Neosurf, Vecuroniu m 25 % dextrose, Aminoven, Calciu m gluconate, Dobutamine, Dopamine, FFP, Frusemide, Heparin, IV antibiotics (Meropenem, Tobramycin ,Fluconazo le) , Maintenance IV Fluids - , Mechanical ventilation, Midazolam, Nasogastric tube feeds, Normal saline, PRBC,
~ 113 ~

Indicativ e Rate &
Upper ceiling (Rs.) PRP, FFP, PhototherapyUmbilical venous and arterial lines, Supplemental Oxygen 7 days, Surfactant therapy Neosurf, Vecuroniu m
803
Term baby with persistent pulmonary hypertension Ventilation-HFO Hyperbilirubinemia Clin ical sepsis Inv - 2D ECHO , Neurosonogram , Blood culture, CRP, ABG, 6 weeks stay with post treatment evidence of clin ical imp rovement and lab investigations
80000
25 % dextrose, Aminoven, Calciu m gluconate, Dobutamine, Dopamine, FFP, Frusemide, Heparin, IV antibiotics (Meropenem - , Tobramycin Fluconazole), Maintenance IV Fluids - , Mechanical ventilation, Midazolam, Nasogastric tube feeds, Normal saline, PRBC, PRP, FFP PhototherapyUmbilical venous and arterial lines, Sodiu m bicarbonate, Supplemental Oxygen, Surfactant therapy Neosurf, Vecuroniu m
~ 114 ~

Indicativ e Rate &
804
Term baby with severe perinatal asphyxia - Non ventilated Clin ical sepsis Hyperbilirubinemia Inv CSF analysis(LP) , CT-Scan , Neurosonogram ,Blood culture, CRP, X-Ray chest 10 days stay with post treatment evidence of clinical improvement and lab investigations
805
Term baby with severe perinatal asphyxia Ventilated Clin ical sepsis Hyperbilirubinemia, Inv - Neurosonogram, CT Scan CSF analysis(LP) , ABG, Blood culture, CRP, Seru m bilirubin, 3 weeks stay with post treatment evidence of clin ical imp rovement and lab investigations
40000
Supplemental Oxygen 25 % dextrose, Calciu m gluconate, IV Phenobarbito ne, IV Phenytoin, IV antibiotics (Piperacillin Tazobactum, Tobramycin ), Maintenance IV Fluids , Midazolam, Nasogastric tube feeds, Normal saline, Physiotherap y, Supplemental Oxygen, Mechanical ventilation, 25 % dextrose, Aminoven, Calciu m gluconate, Dobutamine, Dopamine, FFP, Heparin, Aminoven, IV Phenobarbito ne, IV Phenytoin, IV antibiotics (Meropenem, Tobramycin Fluconazole), Maintenance IV Fluids Midazolam, Nasogastric tube feeds, Calciu m gluconate, Normal saline, PRBC, FFP, PRP, Physiotherap y, Phototherapy-
~ 115 ~

Indicativ e Rate &
Upper ceiling (Rs.) Umbilical venous and arterial lines, Vecuroniu m
806
Term baby Severe hyperbilirubinemia Clinical sepsis Inv - Seru m bilirubin, Blood culture, CRP, X-Ray chest, CSF Analysis, 10 days stay with post treatment evidence of clinical improvement and lab investigations
25000
807
Term baby with seizures ventilated Inv Neurosonogram, CT-Scan brain, Ultrasound abdomen, CSF analysis , Blood ammonia , Lactate, Metabolilc screening-blood and urine ABG , Blood culture, 10 days stay with post treatment evidence of clin ical imp rovement and lab investigations
25000
Double volume exchange transfusion, Double surface Phototherapy, IV antib iotics (Piperacillin Tazobactum, Tobramycin )Maintenance IV Fluids, 25 % dextrose, Calciu m gluconate, Nasogastric tube feeds, Whole blood, Supplemental Oxygen, IV antibiotics (Meropenem Tobramycin, Fluconazole), Maintenance IV Fluids , 25 % dextrose, Calciu m gluconate, Nasogastric tube feeds, Umbilical venous and arterial lines, Aminoven, , Dobutamine, Dopamine, PRBC, FFP, PRP, midazolam,
~ 116 ~

Indicativ e Rate &
Upper ceiling (Rs.) Heparin, IV Phenobarbito ne, IV Phenytoin, Phototherapy, Mechanical ventilation.
808
Necrotising enterocolitis, Clin ical sepsis Non ventilated Hyperbilirub inemia Inv - Blood culture, Abdomen radiograph and ultrasound , LFT , Stool for occult b lood , serum bilirubin, 4 weeks stay with post treatment evidence of clin ical imp rovement and lab investigations
25000
809
Term baby, fu lminant culture positive sepsis, septic shock, Ventilated, Hyperbilirubinemia Renal failure, with Inv - Neurosonogram , Ultra sound of abdomen, 2D ECHO , Abdomen radiograph, , CSF analysis(LP) ,Blood culture, ABG, LFT , Stool for occult blood , Renal function tests, 5 weeks stay with post treatment evidence of clinical improvement and lab investigations
40000
IV antib iotics (Meropenem , Tobramycin Fluconazole), Maintenance IV Fluids , Metronidazol e, 25 % dextrose, Calciu m gluconate, Nasogastric tube feeds, Albumin, Aminoven, Central line, Heparin, ,Normal saline, Phototherapy, Total parenteral nutrition Supplemental Oxygen, mechanical ventilation, IV antib iotics (Meropenem , Tobramycin, Fluconazole), 25 % dextrose, Maintenance IV Fluids , Calciu m gluconate, Nasogastric tube feeds, PhototherapyUmbilical venous and arterial lines,
~ 117 ~

Indicativ e Rate &
Upper ceiling (Rs.) Dobutamine, Dopamine, PRBC, PRP, FFP, Midazolam, vecurnium, Heparin, Aminoven, Adrenaline, Albumin, , Frusemide, Noradrenalin e, Normal saline, , Peritoneal dialysis, Sodiu m bicarbonate, Total parenteral nutrition, Supplemental Oxygen, CPAP, IV antibiotics (Piperacillin Tazobactum1, Tobramycin ), Maintenance IV Fluids , 25 % dextrose, Aminoven, Calciu m gluconate, Heparin, Midazolam, Nasogastric tube feeds, PhototherapyUmbilical venous and arterial lines, Supplemental Oxygen, Mechanical ventilation, 25 % dextrose, IV antibiotics (Piperacillin Tazobactum1, Tobramycin), Maintenance
810
33 to 34 weeks preterm baby Severe Hyaline memb rane disease Clinical sepsis Bubble CPA P Hyperbilirubinemia Inv - X-Ray chest, ABG, Neurosonogram b lood culture, CRP, Seru m bilirubin, 2D ECHO, Neurosonogram, 3 weeks stay with post treatment evidence of clinical improvement and lab investigations
40000
811
33 to 34 weeks preterm baby Severe Hyaline memb rane disease with Clinical sepsis, Mechanical ventilation Hyperbilirubinemia Inv X-Ray chest, ABG, CRP, Seru m bilirubin, Blood culture, 4 weeks stay with post treatment evidence of clinical improvement and lab investigations
60000
~ 118 ~

Indicativ e Rate &
Upper ceiling (Rs.) IV Fluids , Calciu m gluconate, Nasogastric tube feeds, PhototherapyUmbilical venous and arterial lines, Aminoven, FFP, Heparin, Dopamine, Dobutamine, Midazolam, PRBC, FFP, PRP Supplemental Oxygen, 25 % dextrose, IV antib iotics -Meropenem , Tobramycin, Fluconazole, Calciu m gluconate, , Maintenance IV Fluids , Nasogastric tube feeds, Phototherapy, Supplemental Oxygen, 25 % dextrose, IV antib iotics -Meropenem Tobramycin, Fluconazole, Calciu m gluconate, Maintenance IV Fluids , Nasogastric tube feeds, PRBC, PRP, FFP, Phototherapy,
812
35 to 36 weeks Preterm M ild Hyaline memb rane disease Culture positive sepsis Nonventilated Hyperbilirubinemia Inv - X-Ray chest, Blood culture, CRP, CSF Analysis, Seru m bilirubin, 3 weeks stay with post treatment evidence of clin ical imp rovement and lab investigations
35000
813
33 to 34 weeks preterm Mild Hyaline membrane disease Culture positive sepsis - Nonventilated Hyperbilirubinemia Inv - Neurosonogram 2D ECHO , CSF analysis ,Blood culture , CRP, Seru m b ilirubin, X-Ray chest, 4 weeks stay with post treatment evidence of clinical improvement and lab investigations
45000
~ 119 ~

Indicativ e Rate &
814
33 to 34 weeks preterm Severe Hyaline memb rane disease Culture positive sepsis Mechanical ventilation/ Bubble CPAP Hyperbilirubinemia. Inv - Neurosonogram, 2D ECHO, CSF Analysis, blood culture, CRP, S.Bilirubin, X-Ray chest, ABG. 6 weeks stay with post treatment evidence of clinical improvement and lab investigations
Upper ceiling (Rs.) 60000 Supplemental Oxygen, Mechanical ventilation, Surfactant therapy Neosurf, IV antibiotics Meropenem Tobramycin Fluconazole, Maintenance IV Fluids Isolyte P, 25 % dextrose, Calciu m gluconate, Nasogastric tube feeds, Phototherapy Umbilical venous and arterial lines, Aminoven, Dobutamine, Dopamine, FFP, Heparin, Normal saline, PRBC, PRP, Vecuroniu m Supplemental Oxygen, Mechanical ventilation, Surfactant therapy Neosurf, IV antibiotics (Meropenem Tobramycin Fluconazole), Maintenance IV Fluids ,25 % dextrose, Nasogastric tube feeds, PhototherapyUmbilical venous and arterial lines, Aminoven, Dobutamine, Dopamine,
815
30 to 32 weeks preterm Severe Hyaline memb rane disease Clin ical/ Culture positive sepsis Mechanical ventilation Hyperbilirubinemia Inv 2D ECHO, Lu mbar Puncture CSF analysis , Neurosonogram b lood culture, CRP, S. Bilirubin, X-Ray chest, ABG 8 weeks stay. with post treatment evidence of clin ical imp rovement and lab investigations
90000
~ 120 ~

Indicativ e Rate &
Upper ceiling (Rs.) FFP, Heparin, Midazolam, PRBC, PRP, Vecuroniu m
816
<30 weeks preterm Severe Hyaline memb rane disease Clin ical/ Culture positive sepsis Mechanical ventilation Hyperbilirubinemia Inv 2D ECHO , Lu mbar Puncture CSF analysis , Neurosonogram , b lood culture, CRP,S. Bilirubin, X-Ray chest, ABG 10 weeks stay, with post treatment evidence of clin ical imp rovement and lab investigations
90000
817
33 to 34 weeks preterm Severe Hyaline Membrane disease Clin ical/ Culture positive sepsis Patent ductus arteriosus- Medical management Mechanical ventilation Hyperbilirubinemia, Inv 2D ECHO , Neurosonogram, blood culture, CRP, ABG, X-Ray chest Serum bilirubin 6 weeks stay with post treatment evidence of clinical improvement and lab investigations
70000
Supplemental Oxygen, Mechanical ventilation, Surfactant therapy Neosurf, IV antibiotics (Meropenem Tobramycin Fluconazole), IV Fluids - , 25 % dextrose, Nasogastric tube feeds, PhototherapyUmbilical venous and arterial lines, Aminoven, Calciu m gluconate, Dobutamine, Dopamine, FFP, Heparin, Maintenance Midazolam, Normal saline, PRBC, PRP, Vecuroniu m Supplemental Oxygen, Mechanical ventilation, Surfactant therapy Neosurf, IV antibiotics (Meropenem Tobramycin Fluconazole),
~ 121 ~

Indicativ e Rate &
Upper ceiling (Rs.) IV Fluids - , 25 % dextrose, Nasogastric tube feeds, PhototherapyUmbilical venous and arterial lines, Aminoven, Calciu m gluconate, Dobutamine, Frusemide, Dopamine, FFP, Heparin, Maintenance Midazolam, Normal saline, PRBC, PRP, Vecuroniu m Oxygen, I.V flu ids, Inj. Ceftriaxone, Inj. Hydrocortiso ne, Salbutamo l, Budesonide, nebulisations. Oxygen, I.V flu ids, Inj. Pipracillin Tazobactum, Inj. Amikacin, Inj. Methyl prednisolone, Salbutamo l, Budesonide, nebulisations, Mechanical Ventilat ion, Inj. Midazolam Infusion Oxygen, I.V flu ids, Inj. Ceftriaxone + Inj. Amikacin, Salbutamo l, nebulisations.
818
Pediatric Ic Care Respiratory
Severe Bronchiolitis (Non Ventilated) Clinical Photo Inv - ABG OD (ABG -5), X-Ray Chest, 7 days stay PICU with post treatment evidence of X-Ray and Pulse Oxy metry/ABG
15000
819
Severe Bronchiolitis (Ventilated) Inv - CXR A BG 8th hrly (3/day X 7 days), Clin ical Photo with 10 days stay PICU post treatment evidence of X-Ray and Pulse Oxy metry/ABG
20000
820
Severe Bronchopneumonia (non Ventilated) Inv CXR ABG OD 7 days stay PICU with post treatment evidence of X-Ray and Pulse Oxy metry/ABG
15000
~ 122 ~

Indicativ e Rate &
821
Severe Bronchopneumonia (Ventilated) Inv - Serial A BG (3/day X 7 days) X-Ray Chest Clin ical Photo 10 days stay in PICU with post treatment evidence of X-Ray and Pulse Oxy metry/ABG
822
Acute Severe Asthma (Ventilated) Inv - Serial ABG X-Ray Chest 10 days PICU stay with post treatment evidence of X-Ray and Pulse Oxy metry/ABG
35000
823
Severe Aspiration Pneumonia (Non Ventilated) Inv - Serial A BG X-Ray Chest 5 days PICU stay with post treatment evidence of X-Ray and Pulse Oxy metry/ABG Severe Aspiration Pneumonia (Ventilated) Inv Serial A BG X-Ray Chest 7 days PICU stay with post treatment evidence of X-Ray and Pulse Oxy metry/ABG
20000
824
25000
825
ARDS with Mult iorgan failu re Clin ical Photo, Inv - Blood Culture, LFT, RFT, ABG, X-Ray Chest 14 days stay with post treatment evidence of ABG and other Lab Investigations
100000
Oxygen, IV flu ids, Inj. Pipracillin Tazobactum, Inj. Amikacin, Salbutamo l, nebulisations, Mechanical ventilation, Inj. Midazolam Infusion. Oxygen, IV flu ids, Inj. Pipracillin Tazobactum, Inj. Amikacin, Salbutamo l, nebulisations, Mechanical ventilation, Inj. Midazolam Infusion. Oxygen, IV flu ids, Inj. Pipracillin Tazobactum, Inj. Amikacin, Salbutamo l, nebulisations Oxygen, IV flu ids, Inj. Pipracillin Tazobactum, Inj. Amikacin, Salbutamo l, nebulisations, Mechanical ventilation, Inj. Midazolam Infusion. MICU, O2, Antimicrobial s, Ventilat iory Care
~ 123 ~

Indicativ e Rate &
826
827
Pediatric Ic Care Card iovascular
ARDS plus DIC (Blood & Blood products) Clinical Photo, Inv LFT, RFT, Blood Cu lture, X-Ray Chest, ABG, Coagulation Pro file 14 days stay with post treatment evidence of ABG and other Lab Investigations Severe Myocarditis Inv - A BG 12 h rly + ECHO + ECG, CVP monitoring, arterial blood pressure monitoring 10 days stay with post treatment evidence of X-Ray and Pulse Oxy metry/ABG
FFP, Cryo Precip itate, Ventilat iory Care
40000
828
Congenital heart disease with in fection (non Ventilated) Inv - Pulse Oxy metry, Echo X-Ray Chest, CRP 7 days stay in PICU with post treatment evidence of X-Ray and Pulse Oxy metry/ABG
30000
829
Congenital heart disease with in fection and cardiogenic shock (Ventilated) Inv - X-Ray Chest, Serial A BG, Echo, CVP monitoring, arterial blood pressure monitoring 10 days PICU stay with post treatment evidence of X-Ray and Pulse Oxy metry/ABG
50000
Oxygen, IV flu ids, Inj. Pipracillin Tazobactum, Inj. Amikacin, Salbutamo l, nebulisations, Mechanical ventilation, Inj. Midazolam Infusion. Oxygen, I.V flu ids, Inj. Ceftriaxone, Inj. Tobramycin, Inj. Dobutamine, Inj. Dopamine. Oxygen, I.V flu ids, Inj. Meropenem, Inj. Vancomycin, Mechanical ventilation X, Inj. Midazolam, Inotropes, Dobutamine, Dopamine, adrenaline, noradrenaline , milirinone.
Oxygen, I.V fluids, Inj. M eropenem, Inj. Vancomycin, Inj. M idazolam, Inotropes, (Dobutamine, Dopamine, adrenaline, noradrenaline, milirinone.
830
Card iogenic shock Inv - ABG X-Ray chest, Echo, CVP mon itoring, arterial b lood pressure monitoring 10 days PICU stay with post treatment evidence of X-Ray and Pulse Oxy metry/ABG
50000
~ 124 ~

Indicativ e Rate &
831
Infective Endocarditis Inv - 3 Blood cultures at half hourly intervals, ABG X-Ray Chest, Echo 15 days PICU stay with post treatment evidence of X-Ray and Pulse Oxy metry/ABG
832
Pediatric Ic Care CNS
Meningo-encephalitis (Non Ventilated) Inv - CSF analysis, CT-Scan, EEG 14 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
40000
833
Meningo- encephalitis (Ventilated) Inv - Serial A BG, CSF analysis, CT scan, EEG, arterial monitoring 14 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
60000
834
Status Epilepticus Inv - Serial ABG, CSF analysis, CT scan, EEG 14 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
50000
835
Pediatric Ic Care
Febrile Seizures (atypical- mechanical ventilated)
25000
Oxygen, I.V fluids, Inj. M eropenem, Inj. Vancomycin, M echanical ventilation, Inj. M idazolam, Inotropes, (Dobutamine, Dopamine, adrenaline, noradrenaline, milirinone, Inj. Heparin, low molecular weight heparin Oxygen, I.V fluids, Inj. Cefepime, Inj. Vancomycin, Inj. Acyclovir, Anticonvulsant s (Inj. Lorazepam, Inj. Phenytoin (Inj. Phenobarbitone ) Inj. M idazolam infusion Oxygen, I.V fluids, Inj. Cefepime, Inj. Vancomycin, Inj. Acyclovir, Anticonvulsant s (Inj. Lorazepam, Inj. Phenytoin Inj. Phenobarbitone ), M echanical ventilation, Inj. M idazolam infusion Oxygen, I.V fluids, Inj. Cefepime, Inj. Vancomycin, Inj. Acyclovir, Anticonvulsant s (Inj. Lorazepam, Inj. Phenytoin Inj. Phenobarbitone ), M echanical ventilation, Inj. M idazolam infusion Oxygen, I.V
~ 125 ~

Indicativ e Rate &
Upper ceiling (Rs.) CNS Inv - Serial A BG, CSF analysis, CT Scan, EEG 5 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
fluids, Inj. Cefepime, Inj. Amikacin, Inj. Anticonvulsant s (Inj. Lorazepam, Inj. Phenytoin Inj. Phenobarbitone ), M echanical ventilation, Inj. M idazolam infusion Oxygen, I.V fluids, Antibiotics Inj. M eropenem, Inj. Tobramycin, M echanical ventilation, Inj. M idazolam infusion, Inotropes Dobutamine, Dopamine, Adrenaline, noradrenaline, M ilrinone, Anticonvulsant s (Inj. Lorazepam, Inj. Phenytoin Inj. Phenobarbitone ), Inj. Calcium Oxygen, I.V fluids, Antibiotics (Inj. Ceftriaxone, Inj. Ofloxacin, Inj. Amikacin) M echanical ventilation, Inj. M idazolam infusion, endoscopic sclerotherapy, Inotropes (Dobutamine, Dopamine) Oxygen, I.V fluids, Antibiotics (Inj. M eropenem, Inj. Vancomycin) M echanical ventilation, Inj. M idazolam
836
Intra cranial b leed Inv - Serial ABG, CSF analysis, CT Scan, EEG 10 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
40000
837
Pediatric Ic Care GIT
Acute Gastro intestinal bleed Inv - A BG/ Upper GI Endoscopy, USG abdomen 10 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
30000
838
Acute Pancreatitis Inv - ABG, USG abdomen, CT Scan Abdomen, serum amy lase, lipase, CVP monitoring, arterial BP monitoring 10 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
50000
~ 126 ~

Indicativ e Rate &
Upper ceiling (Rs.)

infusion, Inotropes (Dobutamine, Dopamine, Adrenaline, noradrenaline, M ilrinone, Insulin, Inj. Calcium, TPN)
839
Acute hepatitis with hepatic encephalopathy Inv Serial A BG, Bloodsugar 4 hrly, USG abdo men, CT Scan (brain), Hepatic v iral studies (Hepatitis B, Hepatit is C, Hepatit is A, LFT, S. A mmonia) 10 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
50000
840
Pediatric Ic Care Renal
Acute Renal Failu re with dialysis Inv - Serial ABG, X-Ray Chest, Blood Urea cu m Seru m Creat inine 4 hrly, USG abdomen, S.Electro lytes 10 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
40000
841
Pediatric Ic Care Endocrine
Diabetic Ketoacidosis Inv - Serial A BG, Blood sugar 4 hrly, Seru m Electro lytes, CVP mon itoring 8 days PICU stay with post treatment evidence for Clin ical Improvement with biochemical parameters
30000
Oxygen, I.V fluids, Antibiotics (Inj. M eropenem) M echanical ventilation, Inj. M idazolam infusion, Inotropes, Dobutamine, Dopamine, Adrenaline, noradrenaline, M ilrinone, Inj. Calcium, Inj. N-Acetyl Cystein, Inj. Lornathine, LCarnitine, Anticonvulsant s (Inj. Lorazepam, Inj. Phenytoin, Inj. Phenobarbitone ) Oxygen, I.V fluids, Antibiotics (Inj. M eropenem, Inj. Ofloxacin) Inotropes, (Dobutamine, Dopamine) peritoneal dialysis, Inj. Calcium, M echanical ventilation, Inj. M idazolam infusion. Oxygen, I.V fluids, Antibiotics (Inj. Piperacillin Tazobactum, Inj. Tobramycin), Inotropes (Dobutamine,
~ 127 ~

Indicativ e Rate &
Upper ceiling (Rs.)

Dopamine) Calcium, Insulin infusion.
842
Pediatric Ic Care Infection
Septic shock Inv - Serial A BG, Blood sugar 4 hrly, EEG, USG abdomen, CT scan Brain, Echo, ECG, Blood culture, X-Ray Chest, CRP 10 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
50000
843
Pediatric Ic Care Toxicology
Snake bite requiring ventilatory assistance Inv Serial A BG, S. Electro lytes, Blood sugar 4 hrly, EEG, CT scan Brain with 10 days PICU stay with post treatment evidence for Clin ical Improvement with biochemical parameters
50000
844
Scorpion sting with myocardit is and cardiogenic shock requiring ventilatory Assistance Inv - Serial ABG, Blood sugar 8 hrly, Echo, ECG, CVP monitoring, arterial blood pressure 10 days PICU stay with post treatment evidence for Clin ical Improvement with lab investigations
25000
Oxygen, I.V fluids, Inj. M eropenem, Inj. Vancomycin, Anticonvulsant s (Inj. Lorazepam, Inj. Phenytoin, Inj. Phenobarbitone ), Inotropes (Dobutamine, Dopamine, Adrenaline, noradrenaline, M ilrinone). M echanical ventilation, Inj. M idazolam infusion, TPN. Oxygen, I.V fluids, Inj. M eropenem, Inj. Vancomycin, Anticonvulsant s (Inj. Lorazepam, Inj. Phenytoin, Inj. Phenobarbitone ), Inotropes (Dobutamine, Dopamine, Adrenaline, noradrenaline, M ilrinone). M echanical ventilation, Inj. M idazolam infusion, antisnake venom Oxygen, I.V fluids, Inj. M eropenem, Inj. Vancomycin, Inotropes (Dobutamine, Dopamine, Adrenaline, noradrenaline, Sodium nitroprusside),
~ 128 ~

Indicativ e Rate &
Upper ceiling (Rs.)

M echanical ventilation, Inj. M idazolam infusion, antiscorpion venom
845
Poison ingestion/ aspiration requiring ventilatory assistance Inv - Serial A BG, Blood sugar 8 hrly , Echo, X-Ray Chest, ECG, CVP monitoring, arterial blood pressure 7 days PICU stay with post treatment evidence for Clin ical Improvement with biochemical parameters
40000
846
Gen Paediatrics Respiratory
Acute Broncho/ lobarpneumonia with empyema/ pleural effusion Inv - X-Ray, Pus culture, Blood Culture 14 days stay with post treatment evidence of X-Ray Chest
20000
847
Gen Paediatrics Respiratory
Acute Broncho/ lobarpneumonia with pyo pneumothorax Inv - X-Ray, Pus culture, Blood Culture 14 days stay with post treatment evidence of X-Ray Chest
20000
848
Gen Paediatrics CVS
Congenital heart disease with congestive cardiac failure Inv - X-Ray, 2D Echo, ECG, Serial ABG 7 days stay with post treatment evidence of X-Ray Chest, 2D Echo, ECG
15000
Oxygen, I.V fluids, M echanical ventilation, Inj. M idazolam infusion, Inotropes (Dobutamine, Dopamine), specific antidote IV fluids, oxygen, IV Antibiotics (Amoxycillin clavulanate or ceftriaxone, Amikacin, vancomycin), Oral antibiotics, Nebulisations, ICD chest drain, chest physiotherapy, M echanical ventilation if required and oral antibiotics/ Anti tubercular drugs after discharge IV fluids, oxygen, IV Antibiotics, Nebulisations, ICD chest drain, chest physiotherapy, M echanical ventilation if required and oral antibiotics/ Anti tubercular drugs after discharge IV fluids, oxygen, IV Antibiotics (Ceftriaxone, Amikacin or ofloxacin), Nebulisations, diuretics,
~ 129 ~

Indicativ e Rate &
Upper ceiling (Rs.)

Digoxin and mechanical ventilation.
849
Gen Paediatrics CVS
Acquired heart disease with congestive cardiac failure Inv - X-Ray, 2D Echo, ECG, Serial ABG 7 days stay with post treatment evidence of X-Ray Chest, 2D Echo, ECG
15000
850
Gen Paediatrics CVS
Viral Myocarditis Inv - X-Ray, 2D Echo, ECG 7 days stay with post treatment evidence of 2D ECHO , ECG , X-Ray Chest
15000
851
General Paediatrics Renal
Steroid Resistant Nephrotic syndrome Co mplicated or Resistant Inv - Renal biopsy, Electrolytes, Urea, creat inine, Urine exam, X-Ray Chest 2 weeks stay with post treatment evidence of RFT
25000
852
Urinary tract infection with co mplications like pyelonephritis and renal failure Inv - M CUG (Micturating cysto urethrogram), Urine fo r Culture and Sensitivity, Ultrasound 10 days stay with post treatment evidence of Urine Cu lture and USG
15000
853
Acute Renal Failu re RFT, Seru m Electrolytes, C3, C1, Co mp lement levels, Co llagen Vascular profile 10 days stay with post treatment evidence of RFT
10000
854
Acute Renal Failu re with dialysis Inv - RFT, Seru m Electrolytes, C3, C1, Co mplement levels, Collagen Vascular profile 10 days stay with post treatment evidence of RFT.
20000
IV fluids, oxygen, IV Antibiotics (ceftriaxone, Amikacin or ofloxacin), Nebulisations, diuretics, Ace inhibitors, Digoxin and mechanical ventilation. IV fluids, oxygen, IV Antibiotics (ceftriaxone, Amikacin or ofloxacin), diuretics, inotropes and steroids Antibiotics ceftriaxone, Amikacin or ofloxacin), Antihypertensi ve, Diuretics. Immunosuppre ssive, pleural tap/ascitic tap IV fluids,IV Antibiotics (Amoxycillin clavulanate, ceftriaxone, Amikacin or ofloxacin paracetamol, oral antibiotics (Amoxycillin clavulanate, cefixime). Dialysis. Antibiotics, Antihypertensi ve, Diuretics Supportive M anagement, Haemo or Peritoneal dialysis Antibiotics, Antihypertensi ve, Diuretics Supportive M anagement, Haemo or
~ 130 ~

Indicativ e Rate &
Upper ceiling (Rs.)

Peritoneal dialysis
855
General Paediatrics Severe anaemia
856
Thalassemia Majo r requiring chelation Therapy Inv - Hb electrophoresis, Osmotic frag ility test, Seru m Ferrit in 7 days stay with post treatment evidence of Clin ical and Haematological Improvements Haemophilia including Inv - Von Will brands Coagulation studies and Factor analysis 7 days stay with post treatment evidence of Clinical and Haematological Imp rovements Anaemia o f unknown cause Inv - Hb electrophoresis, bone marrow examination, Hierogram 5 days stay with post treatment evidence of Clin ical and Haematological Improvements Pyogenic men ingitis Inv - CSF Analysis & CTScan Brain, Blood Cu lture, X-Ray Chest with post 10 days stay with post treatment evidence of Repeat CSF
Up to 20000
Blood transfusion., Chelating Agents (Oral or Parenteral) Blood and Blood products, Factor concentrate Bloods transfusion, Haematinics etc., IV fluids IV fluids, IV antibiotics (Amoxycillin clavulanate, ceftriaxone, Amikacin or ofloxacin, vancomycin), Paracetamol, IV dexamethasone for below 5 yr. old children, Anticonvulsant s (midazolam or lorazepam, Phenobarbitone or Phenytoin), Ventilatory Support. IV fluids, Naso gastric feeds, IV antibiotics anti tubercular therapy, Paracetamol, IV M annitol, Anticonvulsant s (midazolam or lorazepam, Phenobarbitone or Phenytoin), IV dexamethasone and oral steroids, M echanical Ventilatory Support.
20000
857
Up to 10000
858
General Paediatrics Infections
35000
859
Neuro tuberculosis Inv - CT-Scan Brain CSF ADA analysis, X-Ray Chest 12 days stay with post treatment evidence of Clinical and lab investigation
10000 + DOTS Rx free
~ 131 ~

Indicativ e Rate &
860
Neuro tuberculosis with ventilation Inv - ABG, CT-Scan Brain CSF ADA analysis 12 days stay with post treatment evidence of Clinical and lab investigation
Upper ceiling (Rs.) 20000 + DOT SRx free
861
Suspected Dengue shock syndrome with thrombocytopenia Inv Platelet count and serology with post treatment evidence of platelet transfusion and clinical photograph Cerebral Malaria (Falciparu m) Inv - CSF analysis, Parasite F Test and QBC, Electro lytes, ABG 7 days stay with post treatment evidence of Clin ical and lab investigation
20000
862
10000
863
General Paediatrics Neurology
Convulsive Disorders/Status Epilepticus (Fits) Inv - EEG, CT Electrolytes, Bl. Sugar, S.calciu m, Phosphorous 7 days stay with post treatment evidence of clinical and lab investigation Stroke Syndrome Inv - CT, Angiogram, EEG, 2D Echo 14 days stay with post treatment evidence of clin ical and lab investigation Encephalit is / Encephalopathy Inv - CSF, CT 10 days stay with post treatment evidence of clin ical and lab investigation
10000
IV fluids, Naso gastric feeds, IV antibiotics anti tubercular therapy, Paracetamol, IV M annitol, Anticonvulsant s (midazolam or lorazepam, Phenobarbitone or Phenytoin), IV dexamethasone and oral steroids, M echanical Ventilatory Support. IV fluids, Inotrpopes, Platelet transfusion and supportive treatment. IV fluids, IV antibiotics ceftriaxone, Amikacin, ofloxacin), Oral chloroquine or IV quinine or IV artesunate, Paracetamol, mefloquine, blood and platelet transfusion, mechanical ventilation Anticonvulsant s, IV fluids, Oxygen, ventilator Oxygen, IV Fluids, Anti Epieptics, Low M olecular, heparin IV fluids, M annitol, Anticonvulsan ts, Acyclovir, Inj. Ventilator care Immunoglobuli n, IV fluids, ventilary and supportive care,
864
20000
865
15000
866
Gu illian-Barre Syndrome Inv - CSF Analysis, ENM G Nerve Conduction studies, ABG 15 days stay with post treatment evidence of clinical and lab investigation
60000
~ 132 ~

Indicativ e Rate &
Upper ceiling (Rs.)

Physioherapy
867
Card iology
868
Card iology
869
Card iology
870
Card iology
871
Card iology
872
Card iology
873 874
875
Card iology
876 877
Card iology Nephrology
878
Nephrology
879
Nephrology
Acute MI (Conservative Management without Angiogram) Inv - ECG, CPKM B, Troponin, 2D Echo 1 week stay with post treatment evidence of ECG, 2D Echo, Lab Investigations Acute MI (Conservative Management with Angiogram) Inv - ECG, CPKMB, Troponin, 2D Echo, Coronary Angiography 1 week stay with post treatment evidence of ECG, 2D Echo, Lab Investigations Acute MI with Card iogenic Shock Inv - ECG, CPKM B, Troponin, 2D Echo, Coronary Angiography 2 weeks stay with post treatment evidence of ECG, 2D Echo, Lab Investigations Acute MI requiring IA BP Pu mp Inv - ECG, CPKM B, Troponin, 2D ECHO, Coronary angiography 3 weeks stay with post treatment evidence of ECG, 2D Echo, Lab Investigations Refractory Cardiac Failure Inv - ECG, CPKM B, Troponin, 2D Echo, Coronary Angiography 2 weeks stay with post treatment evidence of ECG, 2D Echo, Lab Investigations Infective Endocarditis Inv - ECG, 2D Echo, Blood C/S 5 days stay with post treatment evidence of ECG, 2D Echo, Lab Investigations Pulmonary Embolis m Inv - M RI/doppler 5 days stay with post treatment evidence of ECG, 2D Echo, Lab Investigations Co mplex Arrhythmias Inv - ECG, Doppler, 3 days stay with post treatment evidence of ECG, 2D Echo, Lab Investigations Simp le Arrhythmias Inv - ECG doppler 3 days stay with post treatment evidence of ECG, 2D Echo, Lab Investigations Pericardial Effusion Tamponade Inv - Doppler 1 week stay with post treatment evidence of ECG, 2D Echo, Lab Investigations Acute Renal Failu re-(A RF) Inv - LFT, S. Protein, Calciu m, Phosphate, uric acid, Electrolytes, Urine protein, USG, ECG, 2D Echo, HIV, HCD, HbSAg 10 days stay in MICU with post treatment evidence of RFT and other lab investigation Dialysis chart Nephrotic Syndro me Inv - LFT, Seru m protein, Seru m electrolytes, 24 hours urine, Urine protein, Chest X-Ray, Biopsy report, USG, ECG, HIV, HCG, HBSAg, ANA/dsDNA, BTCT 4 Days stay with post treatment evidence of RFT and other lab investigation Rapid ly progressive Renal Failure (RPRF) Inv - S. Renal Chemistry 10 days stay with post treatment evidence of RFT and other lab investigation
20000
M edical
30000
M edical
30000
M edical
50000
M edical
50000
M edical
25000
M EDICAL
30000 95000
M EDICAL
Cartoguided
70000
Focus Ablation Aspiration
25000 20000
Dialysis and supportive therapy
15000
Immunosuppre ssive RX
35000
M edicines, Steroids parenteral
~ 133 ~

Indicativ e Rate &
880
Nephrology
881
Nephrology
882
Neurology
Chronic Renal Failure 1 (CRF ) Inv - LFT, S. Protein, S. Ca, S. Po 4, S. u ric acid, A lb/ Globulin ratio S. electro lytes, 24 hrs. urine, Spot Urine /Creatin ine ratio, Chest X-ray, USG, ECG, HIV, HCV, Hb SAg, 2D Echo 5 days stay with post treatment evidence of RFT and other lab investigation Maintenance Haemodialysis for CRF Inv - LFT, S. Protein, S. Ca, S. Po 4, S. u ric acid, Alb/Globulin ratio S. electrolytes, 24 hrs. urine, Spot Urine /Creatinine ratio, Chest X-ray, USG, ECG, HIV, HCV, HbSAg, 2D Echo 1 day stay per dialysis with post treatment evidence of RFT and other lab investigation ADEM or Relapse in Multiple sclerosis Inv - M RI Brain & Spinal cord (3 sites) Plain and contrast, CSF analysis, Evoked Potentials, CSF Monoclonal Bands, HIV Profile 15 days stay with post treatment evidence of Clin ical and Lab Investigations
Initial treatment and Dialysis and supportive therapy
10000 month
Dialysis and supportive therapy (M inimum of 8 dialysis)
20000
883
Neurology
CIDP Inv - NCS, EM G, CSF analysis, Seru m Protein electrophoresis, Nerve Biopsy 10 days stay with post treatment evidence of Clinical and Lab Investigations Haemorrhagic Stro ke/Strokes Inv - CT Brain / MRI Brain / MRV / M RA, ECG, Echocardiography, Carotid and vertebral Doppler etc. special tests for Evaluation of cause, 4-vessel cerebral angio if necessary (DSA), lipid profile 15 days stay with post treatment evidence of Clin ical and Lab Investigations Ischemic Strokes Inv - CT Brain / M RI Brain / MRV / M RA, ECG, Echocardiography, Carotid and vertebral Doppler etc. special tests for Evaluation of cause, 4-vessel cerebral angio if necessary (DSA), lipid profile 15 days stay with post treatment evidence of Clinical and Lab Investigations
8000
884
Neurology
25000
Inj. M ethylprednis olone, supportive care, ventilatory support if necessary, antacids and vitamin supplementatio n, physiotherapy + Oral steroids for 4 weeks Oral steroids, azathioprine, vitamin supplementatio n, physiotherapy antihypertensiv e, antidiabetics, Antacids, M annitol IV, IV fluids as necessary, Surgery if necessary Antihypertensi ve, Antidiabetics, Aspirin + Clopidogrel, Antacids, M annitol IV, Heparanoids for 5 days, IV fluids as necessary, Surgery in some cases
885
Neurology
20000
~ 134 ~

Indicativ e Rate &
886
Neurology
Myopathies - Acquired NCS, Inv - EM G, Seru m CPK, Seru m Calciu m, Phosphate and alkaline phosphatase, endocrine evaluation, Muscle Biopsy 15 days stay with post treatment evidence of Clin ical and Lab Investigations
887
Neurology
NEUROINFECTIONS - Fungal Meningit is Inv CT brain, M RI brain scan, CSF analysis, cell count, ADA, culture, CSF serology for tuberculosis antigens, Fungal studies Min 20 days - ICU, 40 days - ward stay with post treatment evidence of Clin ical and Lab Investigations NEUROINFECTIONS - Pyogenic Meningitis Inv - CT brain, M RI brain scan, CSF analysis, cell count, ADA, culture Min 10 days - ICU, 7 days ward stay with post treatment evidence of Clinical and Lab Investigations
40000
888
Neurology
25000
889
Neurology
890
Neurology
NEUROINFECTIONS - Viral Meningoencephalitis (Including Herpes encephalitis) Inv - CT brain, M RI brain scan, CSF analysis, cell count, ADA, culture, CSF antibodies for HSV Min 10 days - ICU, 7 days - ward stay with post treatment evidence of Clinical and Lab Investigations Neuro muscular (myasthenia gravis) Inv - RNS / CT chest / CT abdomen, Neostigmine test, thyroid profile 15 days stay with post treatment evidence of Clinical and Lab Investigations
25000
Prednisolone + Azathioprine, Calcium supplementatio n, vitamin supplementatio n, Endocrine therapy. Antacids, M annitol IV, steroids, Antifungal drugs, IV fluids as necessary Antacids, M annitol IV, steroids, Higher Antibiotics, IV fluids as necessary, Surgery if necessary Antacids, M annitol IV, methyl prednisolone, Acyclovir, IV fluids as necessary Prednisolone + Neostigmine + Calcium supplementatio ns, Azathioprine, (Surgery for thymoma), Ventilatory care if necessary Inj. M ethylprednis olone, supportive care, ventilatory support if necessary, antacids and vitamin supplementatio n, physiotherapy
15000
891
Neurology
Neuropathies (GBS) Inv - NCS / EM G (1000), Nerve Biopsy (2000), CSF analysis 10 days - ICU 20 days - Ward stay with post treatment evidence of Clinical and Lab Investigations
35000
892
Neurology
Optic neurit is Inv - M RI Brain & Optic nerves, VEPs, CSF analysis 3 days stay with post treatment evidence of Clin ical and Lab Investigations
10000
Inj. Methylpredni solone, antacids and vitamin supplementati
~ 135 ~

Indicativ e Rate &
Upper ceiling (Rs.) on + oral steroids for 2 weeks
893
Neurology
Immunoglobulin Therapy - IV Investigations indicative of d iseases 5 days stay with post treatment evidence of Clin ical and Lab Investigations
100000
894
Pulmonology
895
Pulmonology
Bronchiectasis requiring hospitalisation Inv - HR CT - Chest, spirometry, FOB (Fiberoptic Bronchoscopy), IgE, Sputum culture / drug susceptibility 10 days stay with post treatment evidence of Clin ical and Lab Investigations Lung Abscess, non resolving Inv - CT Scan Chest, FOB, Pus C/S 10 days stay with post treatment evidence of Clin ical and Lab Investigations Pneumothorax (Large/Recurrent) HRCT Inv - Chest , VATS 10 days stay with post treatment evidence of Clin ical and Lab Investigations Interstitial Lung diseases Inv - Sp iro metry, HRCT Chest, Collagen Pro file, Bronchoscopy, 2D Echo 10 days stay with post treatment evidence of Clin ical and Lab Investigations Pneumoconiosis Inv - Spiro metry, HRCT Chest, Collagen Profile, Bronchoscopy, 2D Echo 10 days stay with post treatment evidence of Clinical and Lab Investigations Acute Respiratory Failure (without ventilator) Inv - Seru m Electrolytes, ABG, ECG, 2D Echo, Bronchoscopy, Sputum / Bronchial Washing / ET Suctions for Analysis 10 days stay with post treatment evidence of Clin ical and Lab Investigations Acute Respiratory Failure (with ventilator) Inv Seru m Electrolytes, ABG, ECG, 2D Echo, Bronchoscopy, Sputum / Bronchial Washing / ET Suctions for Analysis 10 days stay with post treatment evidence of Clin ical and Lab Investigations Pemphigus / Pemphigoid Tzanck Inv - Smear Skin Biopsy HPE DIF Clinical Protocol 15 days stay with post treatment evidence of Clinical and Lab Investigations
20000
In several life threatening diseases i.e. rapidly progressive GBS, CIDP, Myasthenia, Multiple sclerosis, etc. According to International Gu ide lines
15000
Antibiotics, Bronchial toilet Thoracostom y + o xygen + antimicrobial s, pleuredesis, MICU Steroids, antimicrobial, MICU Medical Management, MICU Oxygen, Antimicrobial s, Supportive therapy in MICU Oxygen, Antimicrobial s, Supportive therapy in MICU IV Fluids IV Antibiotics IV Steroids Pulse therapy
896
Pulmonology
35000
897
Pulmonology
30000
898
Pulmonology
25000
899
Pulmonology
25000
900
Pulmonology
50000
901
Dermatology
25000
~ 136 ~

Indicativ e Rate &
902
Dermatology
903
Dermatology
904
Rheu matology
905
Rheu matology
Toxic ep idermal necrolysis Inv - LFT, Blood culture, urine Cu lture, Skin swab, USG abdomen Skin biopsy - HPE, Echo - Card iogram 15 days stay with post treatment evidence of Clinical and Lab Investigations Stevens- Johnson Syndrome Inv - LFT, Blood culture, urine Cu lture, Skin swab, USG abdomen Skin biopsy - HPE, Echo - Card iogram 15 days stay with post treatment evidence of Clinical and Lab Investigations SLE (SYSTEM IC LUPUS ERYTHEMATOSIS) Inv - dSDNA, ACL ANTIBODIES, A NA PROFILE, KIDNEY BIOPSY, HRCT, 24 Hrs URINARY PROTEIN, ENANTIGEN 10 days stay with post treatment evidence of Clinical and Lab Investigations SLE with Sepsis Inv - dSDNA, A CL Antibodies, ANA Profile, Kidney biopsy, HRCT, 24 Hrs urinary protein, ENAntigen, Blood culture / proof of sepsis 4 weeks stay with post treatment evidence of Clin ical and Lab Investigations SCLERODERMA Inv - Renal doppler, 2D ECHO, Skin biopsy HPE Report, ANA Profile 7 days stay with post treatment evidence of Clin ical and Lab Investigations MCTD Mixed Connective Tissue Disorder Inv CPK, LDH, ENM G, MRI of muscles, MRI of hands, kidney biopsy 24 Hrs urinary p rotein 7 Days stay with post treatment evidence of Clin ical and Lab Investigations PRIMARY SJOGREN'S SYNDROM E Inv - 24 Hrs Urinary protein , A BG, USG Abdomen 7 Days stay with post treatment evidence of Clin ical and Lab Investigations VA SCULITIS Inv - CANCA, pANCA, ANA profile 10 days stay with post treatment evidence of Clinical and Lab Investigations
IV Fluids IV Antibiotics IV Steroids IV Fluids IV Antibiotics IV Steroids As per American College of Rheu matolog y Guidelines.
20000
15000
50000
As per American College of Rheu matolog y Guidelines.
906
Rheu matology
15000
907
Rheu matology
15000
908
Rheu matology
15000
As per American College of Rheu matolog y Guidelines. As per American College of Rheu matolog y Guidelines. As per American College of Rheu matolog y Guidelines. As per American College of Rheu matolog y Guidelines. IV fluids
909
Rheu matology
10000
910
911
Endocrinology Uncontrolled Diabetes Mellitus With Infectious Emergencies Endocrinology Uncontrolled Diabetes Mellitus With Infectious Emergencies
Pyelonephritis Inv - Urine C/S, USG 10 days stay with post treatment evidence of Clinical and Lab Investigations Lower Respiratory tract in fection Inv - CXR, Sputum C/S 10 days stay with post treatment evidence of Clin ical and Lab Investigations
20000
20000
Insulin
~ 137 ~

Indicativ e Rate &
912
913
914
915
916
Endocrinology Uncontrolled Diabetes Mellitus With Infectious Emergencies Endocrinology Uncontrolled Diabetes Mellitus With Infectious Emergencies Endocrinology Uncontrolled Diabetes Mellitus With Infectious Emergencies Endocrinology Uncontrolled Diabetes Mellitus With Infectious Emergencies Other Endocrinal disorders
Fungal sinusitis Inv - CT PNS 10 days stay with post treatment evidence of Clinical and Lab Investigations Cholecystitis Inv - USG, CT Abd 10 days stay with post treatment evidence of Clinical and Lab Investigations
IV & Oral antibiotics
25000
Antibiotics and Supportive Therapy IV & Oral antibiotics
Cavernous sinus thrombosis Inv - M RI, Venogram, Twice 10 days stay with post treatment evidence of Clin ical and Lab Investigations
40000
Rhinocerebral mucormycosis Inv - CT-Scan, (Brain PNS Chest, Abdomen) when necessary 10 days stay with post treatment evidence of Clin ical and Lab Investigations Hypopitutarism Inv - T3 T4 TSH, basal cortisol post-act cortisol, GH stimulat ion test, FSH, LH, Testosterone or Estradiol GH stimulat ion test 1 yr. needed MRI pic v isual field water deprivation test 1 yr. needed 1 week stay with post treatment evidence of Clin ical and Lab Investigations Pituitary - Acro megaly Inv - Post glucose on assay, prolactin, t3 t 4 TSH, Basal cortisol cost ACTH, FSH / LH, testosterone / estriol, water deprivation test (if needed), M RI co lonoscopy if needed, Visual field, 2D ECHO 1 week stay with post treatment evidence of Clinical and Lab Investigations CUSHINGs Syndro me Inv - Cortisol assay after dexamethasone, ACTH assay, DHEA S, M RI pituitary CTABD, CT Chest, Dexa of Hip spine 1 week stay with post treatment evidence of Clinical and Lab Investigations
40000
IV antifungals
100000
Hormone Therapy for three months
917
Other Endocrinal disorders
15000
Hormone Therapy for three months
918
30000
919
920
Gastroenterology
Delayed Puberty Hypogonadism (ex.Turners synd, Kleinfelter synd) Inv - FSH, LH, testosterone, estradiol, USG pelvis karyotyping, T4 TSH S -ray bone age, X-ray skull, MRI brain DEXA 2D echo 5 days stay with post treatment evidence of Clin ical and Lab Investigations Corrosive Oesophageal injury Inv - Bariu m swallow 7 days stay with post treatment evidence of Bariu m swallow
12000
Diabetes mellitus drugs, Hypertension, Osteoporosis, infection with antibiotics + surgery Inj Testosterone 250mg / 3 wks., oc p ills
20000
Endoscopic dilatation video / photo Medical treatment, MICU stay
~ 138 ~

Indicativ e Rate &
921
Gastroenterology
Oesophageal foreign body Inv - X-Ray one day stay with post treatment evidence of Endoscopic Photograph Oesophageal perforation Inv - CT scan thorax, & abdomen, Bariu m swallow 7 days stay with post treatment evidence of CT Abdomen Achalasia cardia Inv - UGI endoscopy / Bariu m swallow one day stay with post treatment evidence of Endoscopic Photograph Oesophageal Varices, variceal banding Inv - UGI endoscopy one day stay with post treatment evidence of Endoscopic Photograph Oesophageal Varices, sclerotherapy Inv - UGI endoscopy one day stay with post treatment evidence of Endoscopic Photograph Oesophageal Fistula Inv - CT Thorax, Gastrograffin contrast picture 3 days stay with post treatment evidence with post treatment evidence of Photograph of stent in position GA VE (Gastric Antral Vascular Ectasia) Inv UGI Endoscopy 2 days stay with post treatment evidence of Endoscopic Photograph Gastric varices Inv - UGI Endoscopy 3 days stay with post treatment evidence of Endoscopic Photograph Acute pancreatitis (Mild) Inv - USG abdomen, S. Amylase, S. Electrolytes, Ranson's Scoring 1 week stay with post treatment evidence of USG, Lab Investigation Acute pancreatitis (severe) Inv - CT Abdomen, S. Amylase, EUS, RFT, LFT S. Electrolytes, Ranson's Scoring, CXR, A BG 3 weeks stay with post treatment evidence of USG, Lab Investigation Acute pancreatitis with pseudocyst (infected) Inv CT Scan abdomen, EUS, Post Procedure USG 3 weeks stay with post treatment evidence of US G, Lab Investigation
922
Gastroenterology
25000
Foreign body removal photo of the procedure Conservative, MICU stay Dilatation, Botulinu m, Taxim Inj. Endoscopic variceal banding Endoscopic sclerotherapy injection Covered esophageal stent, MICU Medical + Argon Laser Coagulation MICU, Endoscopic Glue Injection MICU
923 924
Gastroenterology Gastroenterology
7000 10000
925
Gastroenterology
5000
926
Gastroenterology
30000
927 928
Gastroenterology Gastroenterology
20000 15000
929
Gastroenterology
Up to 75000 Up to 150000
930
Gastroenterology
MICU
931
Gastroenterology
Up to 30000
932
Gastroenterology
Chronic pancreatit is with severe pain Inv - EUS, CT Scan, Abdomen, ERCP / M RCP 7 days stay with post treatment evidence of Lab Investigation
Up to 20000
933
Gastroenterology
Obscure GI beed Inv - BMFT, Capsule Endoscopy, Enteroscopy biopsy 1 week stay with post treatment evidence of Endoscopic photograph
50000
Endoscopy drainage, Percutaneous drainage, surgical drainage + MICU Conservative, ERCP + Stenting, ERCP, EUS guided, Celiac ganglion block, M ICU Argon Laser Rx
~ 139 ~

Indicativ e Rate &
934
Gastroenterology
Cirrhosis with Hepatic Encephalopathy Inv - UGI Endoscopy, Axcitic fluid analysis 11 days stay with post treatment evidence of Lab Investigation Cirrhosis with hepato renal syndrome Inv Reports of Seru m Chemistry 10 days stay with post treatment evidence of Lab Investigation Biliary structure 1) Post op stent Inv - EUS, MRCP, ERCP, PTBD 7 days stay with post treatment evidence of Radiolog ical & endoscopic image Biliary structure 2) Post op leaks Inv EUS, M RCP, ERCP, PTBD 7 days stay with post treatment evidence of Radiolog ical & endoscopic image Biliary structure 3) Sclerosing cholangitis Inv - EUS, M RCP, ERCP, PTBD 7 days stay with post treatment evidence of Rad iological & endoscopic image Embo lizat ion of A V malformat ion of peripheral extremity, cranio fascial and visceral per sitting Post procedure evidence of Clin ical photograph and Radiographic image Inferior vena cava stenting single stent Post procedure evidence of Clin ical photograph and Radiographic image Hepatic vein Stenting in Budd - Chiari Syndrome single stent Post procedure evidence of Clin ical photograph and Radiographic image Acute stroke thrombolysis with rTPA Post procedure evidence of Clin ical photograph and Radiographic image Renal artery embolization with mu ltiple coils and microcatheter Post procedure evidence of Clin ical photograph and Radiographic image Cortical venous sinus thrombolysis Post procedure evidence of Clin ical photograph and Radiographic image Deep venous thrombolysis for DVT with IVC filter Post procedure evidence of Clinical photograph and Radiographic image Subclavian, Iliac, Superficial Femoral artery stenting each with one stent Post procedure evidence of Clin ical photograph and Radiographic image Tibial angioplasty in critical limb ischemia Post procedure evidence of Clin ical photograph and Radiographic image Mesenteric artery angioplasty & stenting in acute & chronic mesenteric ischemia - Single stent Post procedure evidence of Clin ical photograph and Radiographic image
EVL-EST, MICU 10 days Medical, EVL-EST, MICU 10 days Medical, biliary stent
935
Gastroenterology
40000
936
Gastroenterology
50000
937
Gastroenterology
75000
Medical, biliary stent
938
Gastroenterology
75000
Medical, biliary stent
939
Interventional Radio logy
90000
940 941
Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy
125000 125000
942
100000
943 944
100000 100000
945
125000
946
125000
947
Interventional Radio logy Interventional Radio logy
120000
948
110000
~ 140 ~

Indicativ e Rate &
949
950
Gastrointestinal visceral arterial embolization in upper and lower gastrointestinal bleeding with microcatheter Post procedure evidence of Clin ical photograph and Radiographic image Bronchial Artery Embo lizat ion in hemoptysis using PVA and micro catheter Post procedure evidence of Clin ical photograph and Radiographic image Radiofrequency Tumor Ablat ion Therapy Post procedure evidence of Clin ical photograph and Radiographic image Embo lizat ion of postoperative and post traumatic bleeding Post procedure evidence of Clinical photograph and Radiographic image Inferior Vena Cava Filter placement Post procedure evidence of Clin ical photograph and Radiographic image Biliary drainage procedures - External drainage and stent placement - Single metallic stent Post procedure evidence of Clin ical photograph and Radiographic image Nephrostomy tube and nephroureteral stent placement Post procedure evidence of Clinical photograph and Radiographic image Uterine artery embolization in severe Menorrhagia secondary to PPH, uterine fibroids and AVM Post procedure evidence of Clin ical photograph and Radiographic image Intra-arterial thro mbolysis for acute ischemic limbs Post procedure evidence of Clin ical photograph and Radiographic image Permanent tunnelled catheter placement as substitute for A V Fistula in long term d ialysis Post procedure evidence of Clin ical photograph and Radiographic image Central Venous stenting for Central venous occlusion ( Brachiocephalic, subclavian vein and sup Vena cava) Single metallic stent Post procedure evidence of Clin ical photograph and Radiographic image Endovascular intervention for salvaging hemodialysis AV fistula Post procedure evidence of Clinical photograph and Radiographic image Balloon Ret rograde Transvenous obliteration of bleeding gastric varices ( BRTO) Post procedure evidence of Clin ical photograph and Radiographic image Preoperative portal vein embo lizat ion for liver tumors Post procedure evidence of Clinical photograph and Radiographic image Chemo embolization for liver tumors using drug and PVA or DC beads Post procedure evidence of Clin ical photograph and Radiographic image
60000
951
Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy
120000
952
100000
953
100000
954
100000
955 956
Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy
60000 80000
957
100000
958
40000
959
125000
960
120000
961
100000
962
100000
963
100000
~ 141 ~

Indicativ e Rate &
964
Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy Interventional Radio logy
965 966
967
968 969
970
971 972
Percutaneous vertebro plasty/ cementoplasty (for each level) Post procedure evidence of Clinical photograph and Radiographic image Trans jugular intrahepatic portosystemic shunt (TIPSS) Post procedure evidence of Clinical photograph and Radiographic image Embo lizat ion of Pulmonary A V Malformat ion Post procedure evidence of Clin ical photograph and Radiographic image Preoperative Prophylactic tumor embolization Post procedure evidence of Clin ical photograph and Radiographic image Embo lizat ion of A V malformat ion of brain per sitting with Ony x Post procedure evidence of Clin ical photograph and Radiographic image Carotid stenting single stent with protection device Post procedure evidence of Clin ical photograph and Radiographic image Intracranial arterial and venous stenting Post procedure evidence of Clin ical photograph and Radiographic image Peripheral stent graft for peripheral aneurysms and AV Fistulae Post procedure evidence of Clinical photograph and Radiographic image Embo lizat ion of Caratico-Cavernous Fistula Post procedure evidence of Clin ical photograph and Radiographic image
150000 100000
100000
150000
150000 150000
150000
150000
~ 142 ~
APPENDIX 1 B FOLLOW UP PACKAGE

Sr. No.
System
Package
Rs. Indicative and upper ceiling
First Instalment
Rs. Indicat ive and upper ceiling
Subsequent 3 Instalment
1 Total Thyroidectomy 2 Portocaval Anastomosis Operation of Adrenal Operation of Adrenal 3 Glands bilateral Splenorenal 4 Anastomosis 5 Warren Shunt 6 Spleenectomy + Devascularisation + Spleno Renal Shunt 7 Lap - Pancreatic Necrosectomy 8 Pancreatic Necrosectomy (open) 9 Coronary Balloon Angioplasty 10 Renal Angioplasty 11 Peripheral Angioplasty 12 Vertebral Angioplasty 13 Coronary Bypass Surgery 14 Coronary Bypass Surgery - post Angioplasty 15 CABG with IABP Pump 16 CABG with aneurismal repair 17 With prosthetic Ring 18 Without prosthetic Ring 19 Open Pulmonary Valvotomy 20 Closed mitral Valvotomy 21 Mitral Valvotomy (open) 22 Mitral Valve Replacement (with Valve) 23 Aortic Valve Replacement (with Valve) 24 Tricuspid Valve Replacement 25 Double Valve Replacement (with Valve) 26 Carotid Embolectomy 27 Encephalocele 28 Surgeries On adrenal gland in children 29 Open pylolithotomy 30 Open Nephrolithotomy 31 Open Cystolithotomy 32 Laparoscopic Pylolithotomy 33 Cystolithotripsy 34 PCNL
3000 10000
1200 4000
600 2000
4000 10000 10000 10000 8000 8000 10000 10000 10000 10000 10000 10000 10000 10000 10000 10000 10000 10000 10000 10000 10000 10000 10000 10000 4000 2000 2000 2000 2000 2000 2000
1600 4000 4000 4000 3500 3500 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 1600 800 800 800 800 800 800
800 2000 2000 2000 1500 1500 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 800 400 400 400 400 400 400
~ 143 ~
Sr. No.
System
Package
First Instalment
35 36 37 38 39 40 41
ESWL URSL Endoscope Removal of Stone in Bladder Transurethral resection of prostate (TURP) TURP Cyst lithotripsy Open prostatectomy Craniotomy and Evacuation of Haematoma Subdural
2000 2000 2000 2000 2000 2000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000
800 800 800 800 800 800 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200 3200
400 400 400 400 400 400 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600 1600
42 Craniotomy and Evacuation of Haematoma Extradural 43 Evacuation of Brain Abscess -burr hole 44 Excision of Lobe (Frontal, Temporal, Cerebellum etc. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 Excision of Brain Tumour Supratentorial Parasagittal Basal Brain Stem C P Angle Tumour other tumors Excision of Brain Tumour Subtentorial Ventriculoatrial/Ventriculoperitoneal Shunt Subdural Tapping Ventricular Tapping Abscess Tapping Vascular Malformations Peritoneal Shunt Atrial Shunt Meningo Encephalocele Meningo myelocele Ventriculo-Atrial Shunt Excision of Brain Abscess Aneurysm Clipping External Ventricular Drainage (EVD) Trans Sphenoidal Surgery Trans Oral Surgery Endoscopy Procedures Intra-cerebral Hematoma Evacuation Temporal Lobectomy Lesionectomy Type -1 Lesionectomy Type -2
~ 144 ~
Sr. No.
System
Package
First Instalment
72 73 74 75
Sr. No.
Temporal Lobectomy Plus Depth Electrodes 8000 3200 Stay in General Ward @Rs. 500day 8000 3200 Stay in Neuro ICU @Rs. 4000day 8000 3200 Surgical Treatment (Up to) 8000 3200 FOLLOWUP PACKAGES - MEDICAL Disease Package First Instalment 10000 10000 4000 4000
1600 1600 1600 1600 Subsequent 3 Instalment 2000 2000
1 Acute Severe Asthma with Acute respiratory failure 2 COPD Respiratory Failure (infective exacerbation) Term baby with persistent pulmonary 3 hypertension Ventilation -HFO hyperbilirubinemia Clinical sepsis 4 Term baby with seizures ventilated 5 Acute Severe Asthma with (Ventilated ) 6 Infective Endocarditis 7 Meningo- encephalitis (Non Ventilated) 8 Meningo- encephalitis ( Ventilated) 9 Status Epilepticus 10 Intra Cranial bleed 11 Congenital heart disease with congestive cardiac failure 12 Acquired heart disease with congestive cardiac failure 13 Steroid Resistant Nephrotic syndrome Complicated or Resistant 14 15 16 17 18 19 20 21 22 23 24 25 26 Anaemia of unknown cause Pyogenic meningitis Neuro Tuberculosis Neuro Tuberculosis with ventilation Convulsive Disorders/Status Epilepticus (fits) Encephalitis/Encephalopathy Acute Myocardial infarction Infective Endocarditis Complex Arrythmias Nephrotic Syndrome ADEM or Relapse in Multiple- sclerosis CIDP Haemorrhagic Stroke/Strokes
6000 5000 4000 10000 6500 6500 6500 6500 5000 5000 5000 5000 5000 5000 5000 5000 10000 10000 10000 10000 5000 5000 5000 5000
3000 2000 1600 4000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 4000 4000 4000 4000 2000 2000 2000 2000
1000 1000 800 2000 1500 1500 1500 1500 1000 1000 1000 1000 1000 1000 1000 1000 2000 2000 2000 2000 1000 1000 1000 1000
~ 145 ~
Sr. No.
System
Package
First Instalment
27 Ischemic Strokes 28 NEUROINFECTIONS -fungal meningitis 29 NEUROINFECTIONS - pyogenic meningitis 30 Meningoencephalitis (Including Herpes encephalitis) 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Neuromuscular (myasthenia gravis) Interstitial lung diseases Pneumoconiosis Pemphigus/Pemphigoid SLE (SYSTEMIC LUPUS ERYTHEMATOSIS) SCLERODERMA MCTD MIXED CONNECTIVE TISSUE MCTD MIXED CONNECTIVE TISSUE VASULITIS Hypopitutarism pituitary Acromegaly Delayed Puberty Hypogonadism (ex. Turners synd, kienfelter synd) Gastric Varices Chronic Pancreatitis with severe pain Cirrhosis with Hepatic Encephalopathy Cirrhosis with Hepato renal syndrome
5000 5000 5000 5000 4000 10000 3500 6000 6000 6000 6000 6000 6000 8000 6500 7000 7000 7000 7000 7000
2000 2000 2000 2000 1600 4000 1400 2400 2400 2400 2400 2400 2400 3500 2000 2500 2500 2500 2500 2500
1000 1000 1000 1000 800 2000 700 1200 1200 1200 1200 1200 1200 1500 1500 1500 1500 1500 1500 1500
~ 146 ~
APPENDIX II WORKING PATTERN

Health Camps
Rural /Sub district /District/Women Hospital and Primary Health Centre
Accident sites
Direct to Hospital
Preliminary Verification & Diagnosis Online preauthorization by Insurance and Society doctors of call center through Arogyamitra of network hospital on same day Admission and Treatment Discharge & follow up Billing Claim Processing
Online payment within 7 working days of discharge
Social Audit
~ 147 ~
APPENDIX -III AAROGYAMITHRA Aarogyamithra is Friend of Health; Aarogyamithra is a concept unique to Rajiv Gandhi Jeevandayee Yojana. Aarogyamithras act as facilitators for the patients. In fact they form face of this insurance scheme. Aarogyamithras are to be selected by the stakeholders of Self Help Group (SHG) movement / Local bodies i.e. Gram Panchayat, Municipality, Municipal Corporation/Government Hospital in order to ensure performance efficiency and acceptability among local communities. The following qualifications are prescribed. 1. Graduate 2. Native & Resident of the same PHC area 3. Good communication skills 4. Prefers to move around the villages 5. Functional knowledge of computers Help of local bodies and NGOs may be taken by the insurer to hire the services of local persons in each PHC / Rural / Sub district / General / District Hospital. The working of the Aarogyamithras will be monitored on a daily basis by the regional coordinators and district coordinators of the Insurance Company in coordination with the Gram Panchayat, Municipality, Municipal Corporation, Civil Surgeon, District Administration, etc. All the Aarogyamithras are to be provided with cell phones (CUG connection) by the Insurance Company for instant communication and networking. The Insura nce Company shall also provide uniforms (Aprons compulsorily) for all Aarogyamithras. The following table shows the indicative number of PHCs / Government Hospitals where Aarogyamithras are to be placed:
Districts Population Approx.no of Beneficiary Families No. of PHCs No. of RH SDH 100 SDH 50 GH WH DH Other Hosp. (Corporation/ra ilway / Defense) Medical College Hospitals Total
M umbai City M umbai Suburban Dhule Raigad Nanded Solapur Amravati Gadchiro li
3338031
482073 1340828 398000 570000 545000 831000 560000 183000 4909901
8640419 1707947 2207929 2876259 3849543 2607160

970294 26197582
H. posts182, Disp = 162 41 55 64 77 56 45 682
Hospitals -18 0 1 0 0 1 1 3 0 0 0 0 0 0 18
Medical Colleges4, Dental=3, Specialist Hospitals =5
7 11 12 16 12 10 68
1 1 1 1 1 0 5
1 2 2 2 2 3 12
0 0 0 0 0 0 0
0 0 0 0 1 0 1
1 0 1 1 0 0 15
374 51 70 80 97 73 59 804
Total
In addition to the above the Insurance Company has to select and post at least three Aarogyamithras in each Network Hospitals for round the clock monitoring of the patients. The total number will depend up on the exact number of the Network Hospitals. The insurance Company shall follow the instructions of Rajiv Gandhi Jeevandayee Arogya Yojana Society in this regard. Training of Aarogyamitras Training for Aarogyamitras shall be done by the Insurance Company on the instructions of the society.
~ 148 ~
Role of Aarogyamitras in PHC / CHC / Government/ District Hospitals 1. ROLE OF PHC AROGYAMITHRAS a) IN THE PHC / HOSPITAL Publicity and awareness. Maintain helpdesk at hospital. Receive the beneficiary. Verify the Beneficiary criteria. (Eligibility Criteria) Facilitate consultation with Doctor (PHC Doctor / Nearest Govt. Hospital Doctor) Fill up the referral card. Guide the patient to the next center. To counsel the patients who may require any one of the listed surgeries. To facilitate either to a Government Hospital for further tests or to Network Hospital depending upon the advice of the doctor. To guide the patient to Network Hospital. Follow- up the referred cases. In effect to act as, a guide and friend for the prospective beneficiary families under Rajiv Gandhi Jeevandayee Yojana. Any work assigned by Rajiv Gandhi Jeevandayee Arogya Yojana Society from time to time. b) OUTSIDE THE PHC / HOSPITAL To send daily MIS of the patients. To spread the awareness of the scheme in the villages. To spread the awareness about the scheduled camps by network hospitals in the villages. To coordinate with network hospitals and help conduct ca mps. Mobilize the patients for camps. Follow up the patients identified in the camp to report to network hospital. Coordinate with Civil Surgeons, Medical Superintendents, Gram Panchayat, Municipalities, Corporations, ANMs, Women Health Volunteers and Self- Help Groups for effective implementation of the scheme. Move around the villages and encourage patients to come to avail the benefits of the scheme. Educate villagers about the scheme and distribute brochures and other material. Keep in touch with the District Coordinator. Follow up the Beneficiary families before and after Surgery. Any work assigned by the Rajiv Gandhi Jeevandayee Arogya Yojana Society from time to time. 2. ROLE OF DISTRICT HOSPITAL AAROGYAMITHRAS Apart from the duties enlisted above the Aarogyamithras in District Hospitals will Facilitate the Patient for specialist consultation and tests. Fill up the referral card (part-B) properly. Counsel the patient. Any work assigned by the Rajiv Gandhi Jeevandayee Arogya Yojana Society from time to time. 3. ROLE OF AAROGYAMITHRAS AT NETWORK HOSPITAL Maintain Help Desk at Reception of the Hospital. Receive the patient referred from (PHC or Network). Work round the clock in shift to cater to the needs of emergencies. Verify the documents of the patients. Obtain digital photograph of the patient. Facilitate the Patient for consultation and admission.
~ 149 ~
Liaison with coordinator / administration of the hospital. Counsel the patient regarding treatment / surgery. Facilitate early evaluation and posting for surgery. Facilitate hospital send proper pre-authorization. Follow- up preauthorization procedure and facilitate approval. Follow- up recovery of patient. Facilitate payment of transport charges as per the guidelines. Facilitate cashless transaction at hospital. Facilitate discharge of the patient. Obtain feedback from the patient. Counsel the patient regarding follow-up. Coordinate with PHC / Government Hospital Aarogyamithras for follow up of beneficiary. Follow- up the patient referred by the hospital during the camps. Coordinate with the head-Office and Medical officers for any clarifications. Send daily MIS. Facilitate Network Hospital in conducting Health Camps as scheduled. Any work assigned by the Rajiv Gandhi Jeevandayee Arogya Yojana Society from time to time.
~ 150 ~
PROCEDURE FOR ENROLLMENT OF HOSPITALS

The Public and Private Hospitals will be jointly empanelled within the State of Maharashtra by Rajiv Gandhi Jeevandayee Arogya Yojana Society and Insurance Company following the empanelment procedure lay down by Rajiv Gandhi Jeevandayee Arogya Yojana Society. The hospitals having minimum of 50 inpatient hospital beds with adequate facilities and offering the services as stipulated below shall be empanelled after being scrutinized and recommended by the Empanelment and Disciplinary Committee. Empanelment and Disciplinary Committee will constitute four doctors. Two doctors will be nominated by Insurance Company and two by Rajiv Gandhi Jeevandayee Society. The minimum number of inpatient beds criteria will not be revised from 50. It would be the responsibility of the Insurer for enrolment of Network Hospitals in the State of Maharashtra to give adequate facilities for the treatment of the patients when they present themselves. PROCEDURAL STEPS FOR ENROLLMENT OF HOSPITALS/NURSING HOME: i. Advertise for seeking on line expression of interest from the public and private hospitals ii. Preparation of the short list of the hospitals qualifying eligibility criteria iii. Inspections by joint panel of 4 Physicians to the eligible hospitals for confirmation of eligibility and capacity. iv. Joint panel of 4 Physicians to recommend the eligible for hospital for specific packages v. RGJAY / Selected Insurer would approve the recommendations vi. Send invitation to the administrator of selected hospital for signing MoU. vii. Signing of MoU between Network Hospitals and Insurer. (Please refer Appendix ) (It is worth noting that the procedure of empanelment of hospitals would be ongoing.) Hospital / Nursing Home: means any institution in Maharashtra established for indoor medical care and treatment of disease and injuries and should be registered under Bombay Nursing Home Registration Amendment (2005) Act and Public Hospitals. A. Infrastructure and Manpowe r (General): a. Should have at least 50 inpatient medical beds with adequate spacing of 65 sq. feet per bed with qualified and registered paramedical staff. b. Should have Separate Male and Female General Wards. c. Hospital should be fully equipped and engaged in providing Medical and Surgical facilities for the specialty for which it is to be empanelled. d. In- house round the clock basic diagnostic facilities. (May also have link facilities for high end tests like MRI, CT Scan etc.) e. Fully equipped Operation Theatre of its own wherever surgical operations are carried out with qualified and registered nursing staff under its employment round the clock. f. Post-op ward with ventilator and other required facilities. g. ICU facility with requisite staff. h. Fully qualified doctors of modern medicine should be physically in charge round the clock. i. Casualty with Duty doctor and nursing staff. j. Availability of trained / Qualified / registered paramedics. k. Round the clock availability of specialists in the concerned specialties of support fields within short notice. l. Shall be able to facilitate round the clock advanced diagnostic facilities either inHouse or with Tie-up with a nearby Diagnostic Center. m. Shall be able to facilitate round the clock Blood Bank facilities either In-house or with Tie- up with a nearby Blood Bank.
APPENDIX- IV
~ 151 ~
n. Shall be able to facilitate round the clock Ambulance facilities either own or with Tieup with a nearby Service Provider. o. Maintaining complete record as required on day-to-day basis and is able to provide necessary records of the insured patient to the Insurer or his representative as and when required. p. Having sufficient experience in the specific identified field. q. Shall have all necessary infrastructure required for preauthorization round the clock. r. Should have at least 50 inpatient medical beds with adequate spacing and supporting staff as per norms. 25% beds should be reserved for beneficiary families under Rajiv Gandhi Jeevandayee Arogya Yojana exclusively apart from legal provisions. (At least 12 beds or 25% of total beds whichever is more) In case of c haritable hospitals 10 % beds should be reserved for indigent and 10% for economically weaker sections. Out of remaining 80% beds 25% beds should be reserved for beneficiary families under Rajiv Gandhi Jeevandayee Arogya Yojana exclusively. s. Shall have round the clock laboratory facilities either In-house or with Tie-up with a nearby laboratory with qualified pathologist either inhouse or with tie up. t. Hospital should have line list of procedures carried out in following proforma. 1) Name of patient 2) Age 3) Sex 4) Address 5) Diagnosis 6) Name of surgery / Treatment.7) Date of admission 8) Date of discharge. B. Infrastructure and Manpowe r (Specific): a. For Empanelment of Cancer Therapy Services of fully qualified Medical Oncologist, Radiation Oncologist and Sur gical Oncologist - all or either and equipment for Cobalt therapy, Linear accelerator and Brach therapy all or either to be empanelled for Cancer Surgeries and Chemo and Radio-Therapies. Hospital should have qualified and registered oncologist, oncosurgeon and Radiotherapists. Tumour board comprising of qualified and registered oncologist, oncosurgeon and Radiotherapists will decide comprehensive treatment plan of patient. If hospital has no Radiotherapy equipment and Radiotherapist it should have tie up with nearest Radiotherapy center. Note: A combination of both professional and the equipment is essential. b. For Empanelment of Poly Trauma Shall have Emergency Room Setup with round the clock dedicated duty doctors of Modern Medicine. Shall have round the clock anesthetist services Shall be able to provide round the clock services of Neurosurgeon, Orthopedic Surgeon, CT Surgeon and General Surgeon, Vascular Surgeon and other support specialties. Shall have dedicated round the clock Emergency operation theatre, Surgical ICU, Post-Op Setup with qualified and registered staff. Shall be able to provide necessary cashless diagnostic support round the clock including specialized investigations such as CT, MRI, Emergency biochemical investigations. c) For Empanelment of Pediatric Congenital Malformations and Post-Burns Contractures Shall have Services of qualified specialists in the field Viz. Pediatric Surgeon, Plastic Surgeon with dedicated theatres, post-operative setup and staff. d) For Empanelment of Prostheses (Artificial limbs) Shall have full time services of Orthopedic Surgeon and Prosthetic and orthotic Engineer or technician to be empanelled to provide prostheses package under the scheme.
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e)
Shall facilitate supply, fitting of appropriate prosthesis and gait training of patient by physiotherapist / Occupational therapist. Shall ensure that an appropriate prosthesis is prescribed based on occupation of the person and standard prosthesis is supplied as per quality norms of BIS (Bureau of Indian Standards). Shall also facilitate free replacement of leather parts and ensure total replacement of Prosthesis in case of damage during guarantee period of 3 years. And Hospital shall provide following ame nities for the beneficiary families: 1. Provide space and separate Rajiv Gandhi Jeevandayee counter/ kiosk as per the design for Aarogyamitras (Health Coordinators) 2. Provide Computer with networking (dedicated broadband with minimum 1 mbps speed), printer, scanner, biometric reader and digital camera. 3. Provide free food for the patient including includes morning tea, breakfast, lunch, afternoon tea at 4 PM and dinner. Type of diet should be according to guidance of concerned treating specialist and qualified dietician. 4. Provide one time transport / transportation charges for patient equivalent to State Transport fare or ordinary class of Railway fare from network hospital to taluka headquarter. 5. Free OPD consultation. 6. Free diagnostic tests and medical treatment required for beneficiary families irrespective of surgery. 7. Provide the round the clock services of a dedicated Medical Officer to work as Rajiv Gandhi Jeevandayee Medical Coordinator (MCO) for the scheme and he will be responsible to Rajiv Gandhi Jeevandayee Arogya Yojana Society and the Insurer for doing various activities under the scheme including Health Camps, Follow-up of referred patients form camps, diagnosis, outpatient details, E- Preauthorization, Surgeries, Feedback on the patients condition and services offered by the hospital during hospital stay of the patients, discharges, deaths if any, follow- up free consultation of the patients and distribution of medicines after discharge etc. The Insurance Company shall provide CUG (Closed User Groups) Connection to all MCOs. Selection of hospital for treatment will be according to choice of patient subject to availability of beds in that selected hospital. 8. Provide follow-up with free consultation diagnostics and medicines. 9. Minimum one free Health Camp in village in a fortnight for the screening of the Beneficiary families patient suffering from the identified ailments. Hospital may have a mobile team with diagnostic equipment and team of doctors as specified by the Rajiv Gandhi Jeevandayee Arogya Yojana Society for this purpose. Villages shall be identified by the society in consultation with district administration and communicated to the hospitals / insurance company. Hospital shall provide services of Rajiv Gandhi Jeevandayee medical Camp Coordinator (MCCO) for organization of health camps. The Hospital shall follow the camp policy of the society. The Insurance Company shall provide CUG Connection to all MCCOs.
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APPENDIX- V ACTIVITY CHART FOR INSURANCE COMPANY Activity Number of days re quired to complete the activity from the award date Identifying the Project Officer Tasks will be completed within 7 days of awarding contract Setting up of Project Office with infrastructure in Tasks will be completed within 30 MCGM limits days of awarding contract Appointment of Medical Officers Tasks will be completed before commencement of scheme i.e. 2 October 2011 Establishment of other staff Tasks will be completed before commencement of scheme i.e. 2 October 2011 Preparatory meeting with hospitals Tasks will be completed before commencement of scheme i.e. 2 October 2011 Inspection of hospitals vis--vis scheme requirements, Tasks will be completed before identification of Rajiv Gandhi Jeevandayee Medical commencement of scheme i.e. 2 Coordinator(RJMCCO), signing of MOU and October 2011 Empanelment of Hospitals Issue of CUG connections to RJMCOs and RJCCOs Tasks will be completed before commencement of scheme i.e. 2 October 2011 Installation of kiosk, computer and accessories and 1 Tasks will be completed before mbps connectivity commencement of scheme Printing & distribution of publicity material Tasks will be completed before commencement of scheme i.e. 2 October 2011 Printing & distribution of stationery related to work Tasks will be completed before flow of the scheme. commencement of scheme i.e. 2 October 2011 Appointment of Aarogyamithras Tasks will be completed before commencement of scheme i.e. 2 In PHCs / Govt. Hospitals October 2011 In Network Hospitals Training of Aarogyamithras, distribution of Aprons Tasks will be completed before and CUG mobiles commencement of scheme Training of Doctors Tasks will be completed before commencement of scheme Training of other staff Tasks will be completed before commencement of scheme i.e. 2 October 2011 IT enabling Immediate Establishment of 24 Hrs. Call Center Tasks will be completed before commencement of scheme i.e. 2 October 2011 Establishment of other infrastructure Tasks will be completed before commencement of scheme i.e. 2 October 2011 Establishment of infrastructure in the districts Tasks will be completed before
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Activity
Preparatory meetings and trainings at district level for inaugural mega-camps Handing over of adequate space for office of Rajiv Gandhi Jeevandayee Society in the jurisdiction of Municipal corporation of Greater Bombay.
Number of days re quired to complete the activity from the award date commencement of scheme i.e. 2 October 2011 Tasks will be completed 20 days before commencement of scheme i.e. 2 October 2011 Tasks will be completed before commencement of scheme i.e. 2 October 2011
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APPENDIX VI HEALTH CAMP POLICY Health camps are main source of mobilizing beneficiary families under the scheme. Effective conduct of health camps is key to success of scheme. Activities 1. IEC Activities by network hospitals through Pamphlets, posters, banners. Public address system. Drumbeating. Audiovisual media TV, Local cable. SHG, Village meetings. Exhibitions. 2. Facilities in camp Shade in form of shamiyana. Pedestal fans. Sitting arrangement in form of chairs. Snacks and drinking water. 3. Treatment of minor ailments List of common drugs.
No 1 Category Anti-inflammatory/ Antipyretic/Analgesic Sr No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Form Tab Tab Tab Tab Tab Tab Tab Tab Tab Cap Tab Tab Tab Tab Tab Tab Cap Syrup Syrup Syrup Drug Ibuprofen Paracetamol Aspirin Diclofenac Sodiu m Chlorpheneramine maleate Metronidazole Albendazole Noflo xacin Ciproflo xacin Ampicillin Ranit idine Antacid Multivitamin Iron+Fo lic acid B-Co mp lex Vit C Vit A and D Paracetamol Ampicillin Antitussive Strength 400 mg 500 mg 300/500 mg 100 mg 4mg 400 mg 400mg 400 mg 500 mg 250 mg 150 mg Min Qty 500 1000 500 1000 5000 800 100 1000 5000 500 1000 2000 2000 2000 1000 1000 2000 20 10 20
2 3 4 5
Antiallerg ic Antiamoebic Antihelminthic Antibiotic
6 7 8
H1 Antagonist Antacid Vitamin and supplement
iron
500 mg 125mg/5 ml 125mg/5 ml
For Children
4. Other Activities 1) Provide treatment for common ailments and common drugs in the camps and prevent spread of communicable diseases. Provide free consultation for ailments other than those covered under the scheme. Provide common drugs for general ailments as indicated in the list below. Hospital shall carry at least 10 types of drugs from the above list and should have at least one drug from each category.
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Distribution of all drugs for children ( Category 9) is mandatory. Stock of above drugs must be carried to the camp, however hospitals are free to distribute more number of drugs. Minimum Rs 1500 worth medicines must be carried to the camp. Hospitals may carry generic drugs instead of proprietary preparations to keep cost of medicines low. 2) Network hospitals to provide professional incentives to Government Doctors participating in the camp to encourage their active participation and coope ration. Each Medical officer has to be given incentives of Rs 250. At least two Medical officers from one network hospital or four medical officers if camp is organized by two network hospitals should attend the camp. Each network hospital shall pay incent ive for two medical officers. 5. Allocations In order to encourage the above activities in the camps by network hospitals, Government has decided to provide financial support to the hospitals through RGJAY society to the tune of Rs 5000 for each camp and activity wise allocation of said amount is as listed below. Sr Activity Amount allocated No in Rs 1 IEC Activity 1500 2 Basic necessities to patients such as shamiyana, chairs, water, fans, 1500 snacks etc. 3 Providing common drugs to patients as indicated in the list 1500 4 Incentive to Government Medical officers 500 Total 5000 6. Confirmation of camps, indenting, approval, organizing, claiming and reimbursement of amount. The entire process of intimation, confirmation, indenting, details of camp organization and claiming of money will be through health camp module in the RGJAY society website. The RGJAY society will communicate the schedule of camps well in advance and same will be available online in the login of hospital for confirmation. Confirmation and indenting The details of Doctors and paramedics and equipment to be carried attending camp shall also be indicated online. The indent for each camp should be put up by each hospital online as under. o Details of IEC activities with specific proposals and estimated amount. o Details of facilities to be provided. o Details of common drugs to be distributed. o Incentives to be given to Government Medical officers with names of Medical officers tied for camp. Approval Based on indent RGJAY society will approve amount subject to 5000 rupees per hospital per camp. The approval status can be viewed online. Approved amount can be denied in case of rescheduling camp after confirmation. Organizing the camp The hospital shall conduct camp as per schedule. Hosp ital should ensure that an Arogyawardhini Medical Camp Coordinator (MCCO) is earmarked for the purpose and sent to campsite to undertake camp IEC activities and arrange for facilities provided for the camp. Documentation for camp Each patient is given OPD card. The diagnosis and treatment is mentioned on card. Medicines are given as per prescription and details mentioned in drug dispensing register.
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The signature and thumb impression of patients in Annexure B is scanned and uploaded at the time of claiming camp amount. The referral card is given to patients to patients who are referred under the scheme with details of hospital referred, name of consultant, mobile number of network arogyamithra in Annexure C. The details of outpatients referred and patients will be recorded, a copy of same is signed by Government Medical officer, Medical officer of network hospital and Arogyamithra of network hospital and same is scanned and uploaded online at the time of claiming camp amount. Incentives given to Government Medical officer is obtained in acquaintance in Annexure E. MCCO of network hospital shall also take declaration as to successful conduct of camp signed by MO PHC, Arogyamitra of concerned PHC. Network hospital shall also upload it for claim. Annexure F. Utilization certificate shall be claimed online Annexure G. Reimbursement RGJAY society based on uploaded and submitted documents will reimburse the amount once in a month.
7. Role of District Administration in conducting the camps. 1. Spreading awareness of camp. 2. Camp inaugurated by Local MLA and all Public representatives are informed regarding camp. 3. Drinking water to be arranged by panchayat. 4. Snacks for doctors and staff to be arranged by arogyamitras or Medical officers. Cost will be borne by network hospital. 5. Two MOs from Government and two from network hospital should be deputed for camp. 6. DMHOs shall take necessary steps to distribute common medicines. 7. The patients referred from camps are followed to report to network hospital by Arogyamithras of PHC and Network hospital. 8. District coordinator of RGJAY society and insurance company should speak to AMCCO of network hospital and ensure that all activities are taking place.
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APPENDIX VII DRAFT MOU BETWEEN INSURER AND NETWORK HOSPITAL MEMORANDUM OF UNDERSTANDING RGJAY PHASE I This Agreements is made at Mumbai on this ______ the day of ___ 2011 between ____________________ INSURANCE COMPANY LTD., a Company incorporated under the Companies Act 1956 and having its Registered & Corporate Office at ________________________represented by _________________________hereinafter referred to as Insurer which expression shall unless it be repugnant to the context or meaning thereof shall deem to mean and include its successors and assignees of the ONE PART AND _______________________________________________ rep by Managing Superintendent / Director / Proprietor and having its Registered Office at ___________________________________________________________________________ ______________________________________________________________ hereinafter referred to as PROVIDER which expression shall unless it be repugnant to the context or meaning thereof be deemed to mean and include its successors and assignees of the OTHER PART. WHEREAS, Insurer is an insurance company lice nsed under IRDA to transact Health, Accident and Overseas Medical Insurance, Providing Healthcare insurance coverage to its Insured / Beneficiary families having got the mandate from the Government of Maharashtra to cover yellow ration card holders (BPL) and Orange card holdersne (APL) belonging to 8 (eight) districts namely, Mumbai city, Mumbai Suburban District, Dhule, Raigad, Solapur, Nanded, Amravati, and Gadchiroli, of the State of Maharashtra (Beneficiary families ) against specified surgical / Therapeutic procedures (972 procedures and 121 follow up procedures) for which purpose Insurer has created a network of service Providers . ________________________________________________ desires to join the said network of Providers and is willing to extend cashless medical facilities for the surgical / Therapeutic procedures as per RGJAY Manual on Surgical & Medical Treatments for Cashless Treatment of BPL and APL Population of RGJAY society to members of Below Poverty Line (BPL and APL ) families identified either by RGJAY Health Card or yellow / orange Ration Card and referred to them by the Insurer under the RGJAY Health Insurance Scheme of the Government of Maharashtra. Now this agreement witnesses as under. Article 1: Definitions 1.1 RGJAY society: RGJAY Health Care RGJAY society. 1.2 IRDA: Insurance Regulatory and Development Authority. 1.3 Hospital: Hospital Registered under Bombay Nursing Home Act with minimum 50 beds. HOSPITAL / NURSING HOME: Means any Government institution or Private institution in Maharashtra established for indoor medical care and treatment of disease and injuries and should be registered under Bombay Nursing Home Registration ( Amendment 2005) Act and PNDT Act (Wherever Applicable). II. Infrastructure and Manpowe r (Gene ral): a) Should have at least 50 inpatient medical beds with adequate spacing and supporting staff as per norms. b) Should have Separate Male and Female General Wards c) Fully equipped and engaged in providing Medical and Surgical facilities for the respective specialties
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d) In-house round the clock basic diagnostic facilities for biochemical, Pathological and radiology tests such as Calorimeter/ Auto analyzer, Microscope, X-ray, E.C.G, USG.etc. e) Fully equipped Operation Theatre of its own wherever surgical operations are carried out with qualified nursing staff under its employment round the clock. f) Post-op ward with ventilator and other required facilities g) ICU facility with requisite staff h) Fully qualified doctor(s) of modern medicine should be physically in charge round the clock. i) Casualty/duty doctor/Appropriate nursing staff j) Availability of Qualified/trained paramedics k) Round the clock availability of specialists in the concerned specialties and support fields within short notice. l) Shall be able to facilitate round the clock advanced diagnostic facilities either InHouse or Tie-up facility with a nearby Diagnostic Center m) Shall be able to facilitate round the clock Blood Bank facilities either In-House or Tie- up facility with a nearby Blood Bank n) Shall be able to facilitate round the clock Ambulance facilities either own or Tie-up facility with a nearby Service Provider o) Maintaining complete record as required on day-to-day basis and is able to provide necessary records of the insured patient to the Insurer or his representative as and when required. p) Having sufficient experience in the specific identified field q) Shall have all necessary infrastructure required for preauthorization round the clock r) Shall have round the clock laboratory facilities either In- house or with Tie-up with a nearby laboratory with qualified pathologist either inhouse or with tie up. s) Hospital should have line list of procedures carried out in following proforma. 1) Name of patient 2) Age 3) Sex 4) Address 5) Diagnosis 6) Name of surgery / Treatment.7) Date of admission 8) Date of discharge. III. Infrastructure and Manpowe r (Specific) For Empanelment of Cancer Therapy Services of fully qualified Medical Oncologist, Radiation Oncologist and Surgical Oncologist all or either and equipment for Cobalt therapy, Linear accelerator and Brachy therapy all or either to be empanelled for Cancer Surgeries and Chemo and Radio-Therapies. Hospital should have qualified and registered oncologist, oncosurgeon and Radiotherapists. Tumour board comprising of qualified and registered oncologist, oncosurgeon and Radiotherapists will decide comprehensive treatment plan of patient. If hospital has no Radiotherapy equipment and Radiotherapist it should have tie up with nearest Radiotherapy center. Note : A combination of both professional and the equipment is essential. b. For Empanelment of Poly Trauma 1. Shall have Emergency Room Setup with round the clock dedicated duty doctors of Modern Medicine. 2. Shall have round the clock anesthetist services 3. Shall be able to provide round the clock services of Neurosurgeon, Orthopedic Surgeon, CT Surgeon and General Surgeon, Vascular Surgeon and other support specialties. 4. Shall have dedicated round the clock Emergency theatre, Surgical ICU, Post-Op Setup with qualified staff. 5. Shall be able to provide necessary cashless diagnostic support round the clock including specialized investigations such as CT, MRI, emergency biochemical investigations.
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c. For Empanelment of Pediatric Congenital Malformations and Post-Burns Contractures Shall have services of qualified specialists in the field Viz., Pediatric Surgeon, Plastic Surgeon with dedicated theatres, post-op setup and staff. d. For Empanelment of Prostheses (Artificial limbs) 1. Shall have full time services of Orthopedic Surgeon to be empanelled to provide prostheses package under the scheme. 2. Shall facilitate supply, fitting of appropriate prosthesis and gait training of patient by physiotherapist. 3. Shall ensure that an appropriate prosthesis is prescribed based on occupation of the person and standard prosthesis is supplied as per quality norms of BIS (Bureau of Indian Standards). 4. Shall also facilitate free replacement of leather parts and ensure total replacement of Prosthesis in case of damage during guarantee period of 3 years. and IV. Hospital shall provide following additional benefit to the BPL (Ye llow ration card holder) and APL (orange ration card holders with Annual income < Rs. 100000) beneficiary families related to identified systems: a. Provide space and separate RGJAY counter/kiosk as per the design for Aarogyamithras. b. Provide Computer with networking (dedicated broadband with minimum 1mbps speed), printer, scanner, bar code reader and digital camera. c. Provide free food for the patient d. Provide transport/transportation charges for patient. e. Free OPD consultation. f. Free diagnostic tests and medical treatment required for beneficiary families irrespective of surgery. g. Provide the services of a dedicated Medical Officer to work as Rajiv Gandhi Jeevandayee Medical Coordinator (MCO) for the scheme and he will be responsible to the Society and the Insurer for doing various activities under the scheme including Health Camps, Follow-up of referred patients from camps, diagnosis, outpatient details, E-preauthorization, Surgeries, Feedback on the patients condition and services offered by the hospital during hospital stay of the patients, discharges, deaths if any, follow-up free consultation of the patients and distribution of medicines after discharge etc. The Insurance Company shall provide CUG (Closed User Groups) Connection to all MCOs. h. Provide follow- up free consultation diagnostics and medicines under follow-up packages for 121 identified procedures annexed at provided under the scheme, the package amount will be directly reimbursed to the hospital by the Society. i. Minimum one free Health Camp in village in a week for the screening of the BPL patient suffering from the identified ailments. Hosp ital may have a mobile team with diagnostic equipment and team of doctors as specified by the Society for this purpose. Villages shall be identified by the Society in consultation with district administration and communicated to the hospitals/insurance company. Hospital shall provide services of Medical Camp Coordinator (MCCO) for organization of health camps. The Hospital shall follow the camp policy of the Society. The Insurance Company shall provide CUG Connection to all MCCOs. 1.4 Network Hos pital / N WH: Hospital empanelled under RGJAY. 1.5 MOU: Memorandum of Understanding between the Insurance & Empanelled Hospital. 1.6 Surgery / Surgeries: means cutting abrading, suturing, laser or otherwise physically changing body tissues and organs by qualified medical doctor who is authorized to do so
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1.7 Therapy / Therapies: Standard way of medical treatment to the patient as per the medical protocols of Allopathic medicine. 1.8 Treatment: Medical management by qualified Doctor in the Network Hospital. 1.9 Aarogyamitra: First contact person for RGJAY patient at Network Hospital. 1.10 MCOs (RGJAY Medical Coordinator) - Medical Coordinator from the Network Hospital with minimum MBBS qualification to coordinate with RGJAY society / Insurer 1.11 MCCOs an Officer designated as RGJAY Medical Camp Coordinator for the scheme to coordinate with RGJAY society / Insurer through Arogyamitra. 1.12 IEC: Information, Education & Communication. 1.13 TAT: Turn Around Time. 1.14 Pe r- Authorization: Pre-Authorization is a process by which an Insured Person obtains written approval for certain medical procedures or treatments, from RGJAY society / Insurance. 1.15 EDC: Empanelment & Disciplinary Committee. Article 1a: Effective Date 1a. This agreement will be in force for a period of one year from 02.10.2011 to 01.10.2012 for Phase I. Renewal or unit otherwise terminated as provided for in this MOU an shall be extended by mutual consent under same and conditions. 1b. In case of Renewal intimation of Scheme by the insurer, the Provider agrees to extend services to beneficiary families of RGJAY Scheme beyond the effective date until otherwise terminated and all the services rendered by the Provider shall be considered for subsequent renewal period. Article 2: General Provisions 2.1 General Undertaking: Provider warrants that it has all the required facilities for performing the enlisted surgeries / procedures / therapies as specified in clause. No. 3 2.2 Minimum Bed Stre ngth and Specialty Wise Bed Capacity Provider declares that the hospital has the required number of bed capacity (50) under the scheme and will declare the specialty wise allocation of beds in the Performa submitted below and uploaded in RGJAY society portal.
Code S1 S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12 S13 S14 S15 S17 M1 M2 Total Bed Strength Specialty Total No. of Beds General Surgery ENT Ophthalmology Gynecology & Obstetrics Orthopedics Surgical Gastroenterology Cardio Thoracic Surgery Pediatric Surgery Genito Urinary Surgery Neuro Surgery Surgical Oncology Medical Oncology Radio Oncology Plastic Surgery Polytrauma Prosthesis Critical Care General Medicine
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Code M3 M4.1 M4.2 M4.3 M5 M6 M7 M8 M9 M10 M11 M12 M 13
Total Bed Strength Specialty Total No. of Beds Infectious Diseases Pediatric Intensive Care Neonatal Intensive Care Pediatric General Cardiology Nephrology Neurology Pulmonology Dermatology Rheumatology Endocrinology Gastroenterology Interventional Radiology
2.3 Allocating minimum 25% of beds in network hospital for RGJAY patients: Provider agrees to provide at least 25 % of their bed capacity available for occupation by RGJAY patients for treatment under each specialty available in the hospital and under which the procedures are covered in the RGJAY Scheme. 2.4 Conduct of OP services: 2.4.1 Provider agrees provide separate OP facilities for RGJAY patients. To be manned by Medical Coordinator of the hospital (MCO) and Aarogyamitra(s). 2.4.2 Provider agrees to do general counseling for all OP patients to ascertain their eligibility under RGJAY to avoid later conversion of cash patients at a later date. 2.5 Conve rsion of cash patients into RGJAY: Provider agrees to take a declaration from patient at the time of admission itself on the applicability or otherwise of RGJAY in his/her case. In emergency / trauma cases, patients may be allowed 48 hours after admission to claim RGJAY benefit. 2.6 Online Updating of Bed Occupancy: Provider agrees to upload the bed occupancy under each specialty for which hospital is empanelled as and when required. 2.7 The first point of contact for all the patients (out patients and in patients) coming under the Scheme will be the Aarogyamitra positioned at Network Hospital. 2.8 The Provider agrees to follow ALL the guidelines in rendering the services to RGJAY patient annexed hereto as part & parcel of this MOU. The Provider also agrees to follow and adhere to the guideline issued by the RGJAY society / Insurer from time to. 2.9 The Provider agrees to follow & adhere to the ON-LINE workflow of the RGJAY community Insurance Scheme in providing services to RGJAY patients. 2.10 Eligibility Criteria: The provider agrees to follow the guidelines on eligibility criteria for admission of patients under RGJAY Health Scheme as mentioned here under and the Following guidelines are reemphasized by the RGJAY society to be followed by Network hospital in cases where clarifications are sought.
No Situation Requirement for benefit Valid Yellow or Orange Ration Card coupled with Aadhaar number and in case Aadhaar number not taken any Photo ID card issued by Govt. agencies ( Driving license, election identity card with photograph) to correlate the patient name & photograph. (In instance of emergency ad mission, provisional preauthorization may be given subject to confirmation of it against submission of photo identity before discharge.) Signature & s tamp of Ins urance Agency
No Health Card with beneficiary
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Children born after issue of card i.e. name and photo not available on card or valid yellow/ Orange ration card Name is there in Yellow or Orange Ration Card and matches with name in photo identity. But the card is invalid as it does not match with the digitized list.
Photograph of child with either parent along with Health card/ valid Yellow or Orange ration card of either parent and Birth certificate issued by hospital or other authorized entit ies Not eligib le fo r benefit package (The yello w /Orange ration card is cancelled after verification by department but still the family is holding it)
Satisfactory Performance Certificates from the clients of institutions must be submitted with no adverse reports. These certificates shall be from the clients/end users where diet services were provided. Article 3: Specialty / Specialties Empanelled for 3.1 Provider hereby declares that the hospital has requisite infrastructure as per RGJAY guidelines in relation to specialty services for which empanelment is done and agrees to provide quality diagnostic and treatment services as per the standard protocols. 3.2 Provider hereby declares that hospital did not exclude any other specialty service deliberately from the scheme inspire of having such facility and agrees to empanel for the specialties for which adequate infrastructure is available. 3.3 The Hospital hereby declares that the bed capacity of the hospital is more than 50 with adequate infrastructure and manpower as per standard guidelines and agrees to provide separate male and female wards with toilet and other basic amenities. 3.4 The Hospital declares that it has a well-equipped ICU to meet the emergency requirements of the patients belonging to all categories empanelled for and agrees to facilitate round clock diagnostic and specialist services as per the requirement mentioned in clause 4. 3.5 Specialties Provider agrees not to refuse admission of RGJAY patient in any specialty where it has consultants and equipment. A minimum of 25% of overall bed capacity and of beds in each specialty have to be made available to RGJAY patients in network hospital. 3.6 Provider agrees to follow the guidelines issued by the RGJAY society / Insurer on specific specialties annexed herewith (Refer Annexure V, XXVII) Article 4: Empanelment 4.1 Infrastructure and Manpowe r (General): Well-equipped theatre Casualty / 24 hrs. duty doctor / Appropriate nursing staff Availability of trained paramedics Post-op ward with ventilator and other required facilities. ICU with concerned specialty Round the clock lab and image logy support Availability of specialists in support fields. Facilities for Interventional Radiology and availability of concerned specialist. 4.2 Infrastructure and Manpowe r (Specific): Provider agree to provide to provide the services the services of fully qualified Medical Oncologist, Radiation Oncologist and Surgical Oncologist and equipment for Cobalt therapy, Linear Accelerator and Brach therapy to be empanelled for Cancer Surgeries and Chemo and Radio-Therapies. Note: A combination of both professional and the equipment is essential. If equipment for Radiotherapy are not available, there should be tie up with nearest Radiotherapy center. Chemotherapy and Radiotherapy should be administered only by professionals well versed in dealing with the side-effects that the treatment can cause.
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Patients with Hematologic malignancies (Ex Leukemia, Lymphomas and Multiple Myeloma) and Pediatric malignancies (Any patient < 14 years of age) should be treated by qualified by medical oncologist. Chemotherapy has to be administered to the patient as in-patient treatment only. Provider agrees to provide the services as per the packages and adhere to the treatment protocols (Refer Annexure-IV) The Service Provider will agree to quote batch no. of the drugs and attach empty vials and ampoules with labels intact along with the bills. The Provider will agree to give patients feedback through Multimedia having webcam and mike. The provision for live viewing of the patient will be provided in the RGJAY society portal. 4.4 For Empanelment of Poly Trauma : The Provider will have Emergency Room Setup with round the clock dedicated duty doctor. Provider will have round the clock anesthetist services. Provider will be able to provider round the clock services of Neuron-surgeon, Orthopedic Surgeon, CT Surgeon and General Surgeon, Vascular Surgeon and other support specialties. Provider will have dedicated round the clock Emergency theatre, Surgical ICU, PostOp Setup with qualified staff. Provider will be able to provide necessary cashless diagnostic support round the clock including specialized such as CT, MRI, emergency biochemical investigations. Provider should put all necessary infrastructure required for preauthorization round the clock. 4.5 For Empanelment of Pediatric Congenital Malformations and Post-Burns Contractures: Provider will have services of qualified specialists in the field Viz., Pediatric Surgeon with dedicated theatres, post-op setup and staff. 4.6 For Empanelment of Prostheses (Artificial limbs) The hospital shall have full time services of Orthopedic Surgeon to be empanelled to provide prostheses package under the scheme. Hospital shall facilitate supply, fitting of appropriate prosthesis and gait training of patient by physiotherapist. Hospital shall ensure that an appropriate prosthesis is prescribed based on occupation of the person and standard prosthesis is supplied as per quality norms of BIS (Bureau of Indian Standards). Hospital shall also facilitate free replacement of leather parts and ens ure total replacement of Prosthesis in case of damage during guarantee period of 3 years. 5.7. For empanelment of laboratory services, the signatory should essentially be a qualified pathologist 5.8. For empanelment of Cancer treatment, the facility should have tumour board which decides comprehensive treatment plan of patient. Tumour board should consist of qualified oncologists, oncosurgeon. Linkage to Referral facility for radiotherapy would be permissible. Article 5: Specialties for which empanelment is done No. Specialty Service SURGICAL SPECIALTIES General Surgery Qualified General Surgeon with post
Available / Not Available
Specialist Qualification Name
1.
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No.
Specialty Service graduate degree in General Surgery Well Equipped theatre facility with trained staff Post-op with Ventilator Support SICU Facility Availability of support specialty of General Medicine, Pediatrics. For Laparoscopic Surge ries Surgeon having requisite training and having performed at least 100 procedures for laparoscopic surgery (documentary evidence to be produced) Orthopedic Surgery Qualified Orthopedic Surgeon Well-equipped theatre with C-Arm facility Trained paramedics Well-equipped Post-op facility with Ventilator Support Round the clock lab support with CT,MRI Gynecology and Obstetrics Qualified Gynecologist Expertise trained in laparoscopic procedure with minimum 100 performances Post-op ventilator & Pediatric reconstruction facilities. Support services of Pediatrician Ophthalmology Qualified Ophthalmologist , trained vireo Retinal and orthotics Surgeon Optometry facility Well-equipped theatre facility ENT Qualified ENT Surgeon Well-equipped theatre Post-op with ventilator support Audiology support Cardio-thoracic surgery CT Surgeon CT theatre Cath lab Cardiologist support Post-op with ventilator support ICCU Other cardiac infrastructure Plastic Surgery
1a.
2.
3.
Well Equipped theatre
4.
5.
6.
7.
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No.
Specialty Service Qualified Plastic Surgeon with MCh in plastic surgery or other equivalent degree recognized by MCI Well Equipped Theatre SICU Post-op rehab / Physio-therapy support Neurosurgery Qualified Neuro-Surgeon (M.Ch. Neurosurgery or equivalent Well Equipped Theatre with qualified paramedical staff Neuro ICU facility Post-op with ventilator support Step down facility Facilitation for round the clock MRI, CT and other support bio-chemical investigations Urology Qualified urologist Well-equipped theatre with C-ARM Endoscopes investigation support Post-op with ventilator support Sew lithotripsy equipment Pediatric Surgery Qualified pediatric surgeon Well-equipped theatre Pediatric and Neonatal ICU support Post-op with ventilator and pediatric resuscitator facility Support services of pediatric Surgical Gastroente rology Qualified Surgical Gastro- Enterologist Well Equipped Theatre Endoscope equipment Post op with ventilator support Centre Must have done at least 100 Endoscope Surgeries SICU MEDICAL SPECIALTIES General Medicine Qualified General Physician with post graduate degree in General Medicine, Or Equal General Medicine Qualified General Physician with post graduate degree in General Medicine , Or Equal General Medicine
8.
9.
10.
11.
B. 1.
2.
3.
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No.
Specialty Service Qualified General Physician with post graduate degree in General Medicine, or Equal Pediatric Qualified pediatrician NICU & PICU fully equipped Round the clock Pediatric / Emergency service room with Pediatrician Pediatric resuscitation faculty Cardiology Qualified Cardiologist with DM or Equivalent Degree ICU Facility with cardiac monitoring and ventilator support Hospital should facilitate Round the clock cardiologist services Availability of support specialty of General Physician & Pediatrician Cardiac Interventions and Procedures Qualified Cardiologist with experience in interventions and procedures Fully equipped Cath lab Unit with qualified and trained Paramedics Must have Backup CT Surgery Unit to perform Cardiac Surgeries. Centre Must have done at least 100 interventions Nephrology Qualified Nephrologists with DM or Equivalent Degree Hemodialysis facility AMC and Physician Support Medical-Gastro Entomology Qualified Gastro Enterologist with DM or Equivalent Degree. Endoscopy facility AMC and Physician Support Centre Must have done at least 100 Endoscopic procedures Endocrinology Qualified Endocrinologist with DM or Equivalent Degree AMC with ventilator and Physician Support. Neurology Qualified Neurologist with DM or Equivalent Degree. EEG, ENMG, Angio-CT facility of
4.
5.
5a.
6.
7.
8.
9.
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No.
Specialty Service Neurological study Neuro ICU Facility with ventilator support Physician Support Dermatology Qualified Dermatologist with MD or Equivalent Degree. AMC and Physician Support. Pulmonology Qualified Pulmonologist RICU facility Spirometry and bronchoscope facility Physician Support Rheumatology Qualified Pulmonologist MICU Facility Physician and Orthopedic Support Physiotherapy Support COMMINED SERVICES FOR CANCER THERAPY Cancer Services of qualified Medical Oncologist Services of qualified Surgical Oncologist Services of qualified Radiation Oncologist if inhouse Radiotherapy equipment. Fully equipped Radiotherapy Unit SICU or tie up with nearest Radiotherapy center. Interventional Radiology Availability of DSA equipment Qualified and trained interventional radiologists
10.
11.
12
C 1.
Article 6: Cashless Services under Package 6.1 The Provider agrees to provide total cashless transaction to the Beneficiary right from his reporting to discharge under the scheme. 6.2 Provider agrees to provide treatment as per the packages worked out by the RGJAY society the package includes consultation, medicine, diagnostics, implants, food, cost of transportation, hospital charges etc. In other words the package should cover the entire cost of patient from date of reporting to his discharge from hospital 10 days after surgery, making the transaction truly cashless to the patient. And under no circumstances shall charge any money extra within the treatment period of package. 6.3 The Provider agrees to issue a test requisition slip to the patient which will empower the patient to approach the concerned diagnostic/test centers within the hospital or otherwise and do the tests without any cash transaction. The details of the Tests done and their results will be uploaded in the portal by the MCO of the Provider.
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6.4
Provider agrees to keep all the RGJAY patients admitted till 10 days of postoperative or till patient recovered satisfactorily in all those cases where operation was performed. 6.5 The hospital agrees to the package to be authorized even for those patients who were admitted as non-RGJAY out of ignorance but subsequently identified as RGJAY beneficiary during the course of his/her stat in the hospital. In the meanwhile ant payment received from the patient shall be refunded immediately after getting preauthorization approval and before discharge of the patient from the hospital duly obtaining a receipt from the patient. 6.6 Hospital shall assist and facilitate the patient to procure compatible blood for the surgeries and therapies. The Hospital shall provide blood from their own blood bank subject to availability within the package. In case of non-availability the hospital shall make efforts to procure from other blood banks, Red Cross, Voluntary Organizations, etc. The Hospital shall also issue a copy of the request letter to the patient. Article 7: Package Rates 7.1 The Package rates are given in the Booklet (RGJAY Manual on Surgical & Medical Treatments for Cashless Treatment of beneficiary Population) will form a part and parcel of the MOU and which will be the basis and binding for the treatment cost of various procedures and as per the package rates. 7.2 The Package rates are the maximum rate indicated for each surgical procedure However, the settlement of the claims will be made on the basis of actual bill submitted by the provider. 7.3 Provider has agreed to the continuation of the agreed tariff for the period of this agreement. 7.4 In the event of more than one procedure is being undertaken in one sitting other than those of routine/standard components of the surgical procedure, the package amount will be decided by the technical committee in consolation with treating doctor and decision of this committee will be final and binding on the hospital. 7.5 Provider under any circumstances will not refuse to undertake procedure on the ground of insufficient package. 7.6 In all other disputes related to package rates and technical approvals of preauthorizations the matter will be referred to a technical committ ee of the RGJAY society and decision of the committee is binding on the provider. Article 8: Cost of evaluation of patients 8.1 The cost of various treatment/tests conducted on the beneficiary family members who are evaluated but ultimately do not undergo Surgery or Therapies will be borne by the Provider themselves and the Provider will not charge any fee for consultation and investigation from the Beneficiary. Article 9: Quality of Services 9.1 Provider agrees to provide separate and Free OPD consultation. However there will not be any discrimination to RGJAY patients vis-a-vis other paying patients in regard to quality of services. 9.2 Provider shall agree to provide free diagnostic tests and medical treatment for beneficiary families irrespective of surgery / Therapy required according to good business practices. 9.3 The Provider will treat RGJAY Beneficiary families in a courteous manner and according to good business practices. 9.4 The Provider will extend admission facilities to the Beneficiary families round the clock. 9.5 The Provider will have themselves covered by proper indemnity policy including errors, omission and professional indemnity insurance and agrees to keep such policies in force during entire tenure of the agreement.
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9.6
Provider will ensure that the best and complete diagnostic, therapeutic and follow-up services based on standard medical practices / recommendations are extended to the Beneficiary. 9.7 The provider agrees to provide quality service to the beneficiary by following standard protocols for diagnosis and treatment. It is also mandatory for the provider to assess the appropriate need and subject the beneficiary for treatment / Procedure. 9.8 The provider agrees to provide quality medicines, standard prostheses. I mplants and disposables while treating the beneficiary families. 9.9 The Provider agrees to assist and cooperate with the medical auditing team from the RGJAY society / Insurer as and when required. 9.10 The Provider agrees to provide video recorded evidence of patient counseling before surgery in order to avoid legal complications / any adverse reaction by patients or Patients relatives or by public in the event of unacceptable outcome. 9.11 The hospitals Morbidity and Mortality cases will be subject to scrutiny by the RGJAY society / Insurer. (Refer ANNEXURE V & XIV) 9.12 The provider agrees to take sole responsibility in submitting the patient details online and if any discrepancy is found in this regard the Provider agrees to abide by decisions of EDC. Article 10: Services of Medical Coordinator Provider will have a Medical Officer / Medical Officers designated as RGJAY Medical Coordinator/s (MCO) for the scheme to coordinate with society through Arogyamitra. The provider agrees to submit the details of appointed MCO s as per the ANNEXURE XXII The provider should promptly inform the insurer about change if ant in the MCO designated the tenure of the agreement. The following will be the responsibility of MCOs (RGJAY Medical Coordinator): 1. He / She will ensure that all required evaluation including diagnostic tests are done free of cost for all beneficiary families and the details of the same along with reports are captured in the RGJAY society portal. 2. He / She will upload the OP/IP status of the patient. 3. He / She will guide the patient in all aspects and sign the investigation request. 4. He / She have to cross check whether diagnosis is covered in the scheme. If doubtful about the plan of management then should coordinate with treating specialist along with Package list as specified in the Rajiv RGJAY Medical on Surgical & Medical Treatments for Cashless Treatment of BPL Population 3rd edition. 5. He / She should facilitate the admission process of Patient without any delay. 6. After admission He / She will collect all the necessary investigation reports before sending for approval. 7. He / She will upload the admission notes and preoperative clinical notes of the patient. 8. He / She will ensure that preauthorization request is sent only for those who are on bed (IP) 9. He / She will ensure before sending Preauthorization that all documents like health card or valid ration card (yellow/orange) coupled with aadhar number, Patient photo and also necessary reports like CT Films, X-Ray films, Angio CD etc. are uploaded in the system. 10. He / She will coordinate with insurance and RGJAY society doctors as need arises. 11. Preauthorization kept pending from Insurance and RGJAY society will be verified on a regular basis and necessary corrections to be done by MCO. 12. He / She will furnish daily clinical notes (Per Operative and Post-operative).
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13.
He / She will upload 3 Photographs of the Patient taken preoperative bedside, immediate post-operative showing operation wound and at the time of discharge. 14. He / She will update surgery and discharge details and hand over signed copy of the summary along with follow- up advice in preprinted stationary supplied. 15. He / She will ensure free follow up consultations, routine investigations and distribution of drugs to be supplied by the Provider to the beneficiary families. And also refer ANNEXURE VI 16. He / She will ensure to update the details of on bed status of patients time to time as per the format (Refer ANNEXURE-XX) on the display board placed at the Arogyamithra Kiosk / reception desk. 17. The Provider will have a Data Entry Operator and each data entry operator will be linked to the respective MCO and the final responsibility of the data fed by the data entry operator will be vested on MCO of the Hospital. The provider agrees to submit the details of Data Entry Operator as per the ANNEXURE XXV. Article 10.1 Mode of communication 10.1 (i) The Provider agrees to use the Closed User Group (CUG) mobile pho ne given by insurer to MCOs & MCCOs exclusively for the purpose official communications related to RGJAY Scheme. Any mis-utilization of CUG by the MCOs & MCCOs the insurer reserves the right to initiate action against the service Provider. (ii) The Provider agrees to use only RGJAY Messaging Services provided on the Web Portal for any kind of official communications related to RGJAY scheme. The EmailIds of MCOs & MCCOs provided by the RGJAY society/ Insurance will be used as their communication method. Article 11 Documentation and MIS 11.1 The provider will ensure that documentation of RGJAY patients are done using standard formats supplied / available online such as admission card, referral card, investigation slip, discharge summary etc. 11.2(i) RGJAY society Insurer reserves the right to visit the Beneficiary and check his medical data with or without intimation as and when required. (ii) The provider will allow the General Managers / Deputy General Managers / Field staff / Doctors. Vigilance officials and other officials from the RGJAY society and Insurance Company to inspect the hospitals without obstruction and co-ordinate with them during Surprise and Regular Inspections. 11.3 Provider will furnish periodical reports to RGJAY society / insurer on the progress of the scheme as per the formats prescribed for this purpose. 11.4 Provider will not give any document to facilitate the RGJAY patient to obtain any other relief like CMRF etc. Provider will not claim any other relief for the procedures covered under the scheme. Any deviation in this regard may attract Delisting of the hospital. 11.5 The Provider agrees to keep printouts of all online documents in the case sheet and make available as and when required for verification by field staff / doctors of the RGJAY society / Insurance. Article 12: Display of Boards & Banners 12.1 Provider agrees to display their status of preferred Provider of RGJAY Community Health Insurance Scheme at their reception / admission desks. 12.2 Provider agrees to display their status of specialties empanelled in RGJAY Community Health Insurance Scheme at their reception / admission desks. 12.3 Provider agrees to display availability of beds in the hospital and also display specialty wise bed occupancy under RGJAY Community Health Scheme at their reception / admission desks. (Refer ANNEXURE-XX)
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12.4
Provider agrees to display the process flo w of RGJAY within the hospital at the RGJAY kiosk. 12.5 Provider agrees to make available of the list of diseases with package rates covered under RGJAY community Health Insurance scheme in the form of Booklet supplied by the RGJAY society/ Insurer at their reception / admission desks. 12.6 Provider agrees to display other materials supplied by RGJAY society /Insurer for the ease of Beneficiary families. Article 13: RGJAY Kiosk and Aarogyamithra Services 13.1 The Provider will allow RGJAY Assistance Counter / Kiosk to be established at the reception of the Provider free of cost. (Photograph of the space annexed herewith (Refer ANNEXUR-1)) 13.2 The Provider will provide following infrastructure and network facility to the counter. P.C., Printer, Scanner, Digital Camera, Webcam, Barcode reader, Mike, Speakers, Stationary etc. (Refer ANNEXURE - XVII) The System and other peripherals should be provided exclusively for the use of Aarogyamithra who can use the resources at any point of time. 13.3 The Provider will provide a dedicated 2MB broadband connectivity to the Computer to be exclusively used by the Aarogyamithra to access the web for online MIS. epreauthorization etc. 13.4 The Provider will allow Aarogyamithra access to the wards and patients data to facilitate onward transmission to the Company for e-pre-auth, claims, correct MIS etc. 13.5 The Provider will update the date of surgery, discharge / death of the beneficiary in the RGJAY society portal. 13.6 The Provider will intimate Aarogyamithta and MCO regarding emergency admissions of the Beneficiary during non office hours. Article 14 Preference to Beneficiary families 14.1 The Provider agrees not to deny admission for the beneficiary for want of preauthorization approval. 14.2 The provider agrees to provide a separate ward for RGJAY Beneficiary families. 14.3 The provider agrees to provide separate Operation Theatre and weekly schedules for the surgeries / therapies to be performed for the Beneficiary families. Article 15 Capacity for Surgeries 15.1 The provider agrees to handle a minimum number of cases in each specially including trauma cases based on their available infrastructure as under: CATEGORY SPECIALTY Capacity to admit number of patients /Day (Bed Strength) A MEDICAL SPECIALTIES General Medicine Critical Care General Medicine Infectious Diseases Pediatrics Neonatal Intensive Care Pediatric Intensive Care Pediatrics (General) Cardiology (Medical Management) Nephrology Neurology Endocrinology Medical Gastroenterology
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CATEGORY
SPECIALTY
Capacity to admit number of patients /Day (Bed Strength)
Dermatology Rheumatology Pulmonology B SURGICAL SPECIALTIES General Surgery Orthopedics ENT Ophthalmology Gynecology and Obstetrics Cardiac Interventions Cardiothoracic Surgery Surgical Gastroenterology Genitourinary Surgery Neuro Surgery Pediatric Surgery Plastic Surgery C SPECIAL SERVICES Cancer Medical Oncology Surgical Oncology Radiation Oncology* 15.2 The Provider agrees to submit the vacancy level in pre-operative words, ICU, PostOperative wards and also upload the same in the RGJAY society portal on a daily basis. Article 16 Medical Camps 16.1 The Provider will conduct free medical camps at least once a week at the place specified by the RGJAY society to identify the members of the BPL families who may require surgeries covered under the scheme as per the schedule given by the RGJAY society/for such surgeries. The camp policy as given in Annexure II will be scrupulously followed. 16.2 The Provider will carry necessary diagnostic equipment such as ECG, Echo Ultrasound etc. to these free medical camps. 16.3 The Provider will provide services of concerned specialists namely Cardiologists, CT Surgeon, Neurosurgeons, Urologists, Oncologists, Gynecologists. Plastic Surgeon, Pediatric Surgeon, General Physicians to the camp to facilitate proper evaluation of the patients. 16.4 The Provider will submit the camp confirmation and indent (Annexure-III) online as given in camp policy in the prescribed format to RGJAY society/ Insurance at least one week in advance of the stipulated date. 16.5 The Provider will inform all the stakeholders such as district Administration, concerned public representatives, PHC / AH / DH staff etc. well in advance for successful conduct of the camp. 16.6 The Provider will spread awareness about the camp through Publicity in coordination with District Coordinator. Regional coordinator, PHC staff and Aarogyamithras. 16.7 The Provider will provide patient data to RGJAY society / Insurance in the prescribed form at the end of the camp. 16.8 The Provider will enter the details of the patients screened and referred at the camps on the RGJAY society website on the same day of the camp.
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16.9
The Provider will coordinate constantly with the Medical camps cell of the RGJAY society in all matters related to Medical camps. 16.10 The patients referred from the camp will be followed up and transported to the Hospital within 10 days of the camp unless the patient is not willing, in which case the same should be recorded and updated in the Website. 16.11 Provider will have an Officer designated as RAJIV GANDHI JEEVANDAI Medical Camp Coordinator (MCCOs) for the scheme to coordinate with RGJAY society / Insurance through Aarogyamithra The provider agrees to submit the details of appointed MCCOs as per the ANNEXURE XXIV. The provider agrees to inform the insurer & RGJAY society about the change in the MCCO designated if any, during the tenure of the agreement. The Provider will give the full time services of RGJAY Medical Camp Coordinator (MCCO) to coordinate all activities related to camps and patient follow up from camps. The following will be the responsibilities of RGJAY Medical Camp Coordinator (MCCOs) Confirmation of camps online and indenting online. Carrying out the IEC activities within camp area at least 7 days before the camp date. Providing facilities like shamianas, chairs, screening enclosures. Providing common medicines in the camps. Arrange for distribution of incentives to the medical officers. Coordinating and ensuring participation of specialists. Arranging the diagnostic equipment Coordinate with PHC doctors / government Doctors. Public Representatives, SHG groups and Local Administration. Raising claims online for the camps conducted. Follow up of patients referred from Camps as per clause 16.10 And other responsibilities mentioned in ANNEXURE XV. Article 17: Admission of Beneficiary 17.1 Request for examination and if necessary hospitalization for surgical procedures on behalf of the Beneficiary will made by the RGJAY Help Desk at PHC/ Government Hospital or by the RGJAY Assistance Counter / Kiosk at Network Hospital. 17.2 Aarogyamithras at RGJAY Assistance Counter / Kiosk at the Network Hospital will coordinate with the Provider from the time of admission till discharge after the surgical procedure. Article 18: e-Pre- Authorization 18.1 Pre-authorization request will be sent only after admission and the patient will be there in the hospital as inpatient till final decision on the Preauthorization is made. 18.2 The Provider will submit the e-pre-authorization, after admitting the patient as inpatient, on the RGJAY Website complete in all aspects including the signed copy of consent of the patient. All relevant test reports along with Digital photograph of the Beneficiary taken in the hospital should also be uploaded. Catheterization CD, MRI films, X-rays, biopsy reports will be uploaded, cytology and biopsy reports / slides should be submitted. 18.2a Insurer undertake to approve the Preauthorizatio n in consultation with the RGJAY society indicating the relevant package rates within 12 working hours of the receipt of the request for pre-authorization form as well as the required data and information online. 18.2b the Provider agrees to update the surgery online immediately after performing the Surgery. However, the validity period of the pre-authorization is 14 days from the date of approval. The Provider agrees to update clinical notes of ALL cases (both Pre
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18.2c
18.2d
18.2e
18.2f
18.3
18.4
18.5
18.6
& Post pre-authorization notes) in the Website on daily basis. If the surgery / therapy is not update within 14 days after approval of pre authorization will automatically get cancelled in the RGJAY Portal. The provider should obtain fresh approval for the cancelled pre-authorization by mentioning valid reasons and the Insurer / RGJAY society reserves the right to approve the request of pre-authorization. After Approval of pre-authorization, if the patient is not found on bed at the time of routine check by officials of RGJAY society Insurer and in case the provider unable to present the patient during the routine check by officials of RGJAY society/Insurer, the RGJAY society/ Insurer reserves the right to cancel the Preauthorization immediately without any intimation. If the provider is not able to conduct the operation within a reasonable time for any reason other than medical such as non availability of beds or specialists, the Provider will arrange for the operation to be conducted at any other appropriate Network Hospitals in consultation with Insurer. The provider agrees that the approval of Pre-authorization by RGJAY society / Insurance is mere approval for eligibility of case for Assistance under scheme and should not be construed as approval of choice of the treatment & outcome consequences thereof which is sole responsibility of treating Doctor. Any deficiency in documentation & ONLINE updation of data and protocols by the provider which may lead to pending of Pre-authorization approval, the responsibility for such delay leading to delay in treatment & outcome is solely responsible of the Provider. The provider agrees that any Rejection of Pre-authorization shall not be construes as denial of treatment to the patient and outcome thereof, it is a mere rejection of assistance under the scheme guidelines. The provider agrees to exercise best of his judgment and counsel the patient about the alternate ways of providing such care including the option of referring the patient to Govt. Institution where such facility exists. Preauthorization preferably will be given to the network hospital whichever does the preliminary screening either at the Medical camp or at the hospital. Second preauthorization for the same patient from different network hospital will not be entertained for the same procedure unless medically warranted or surgical procedure is unduly delayed by the first hospital without proper medical grounds. Insurer reserves the right to disallow the claim if the Surgery / Therapy is performed before any approval from the Insurer / RGJAY society and pre-authorization is obtained at a later date keeping the insurance / RGJAY society in dark about the surgery /therapy. The provider agrees to send the enhancement requests before the discharge of the patient through E-mail or by fax and follow the enhancement guidelines (ANNEXURE-XXI) and enhancement module manual in the booklet (RGJAY manual for Surgical and Medical treatments for Cashless Treatment of BPL Population- 3rd edition.) The Provider agrees to abide by the decision of Technical Committee and shall extend cashless facility to the patient. The provider agrees to obtain emergency Telephonic Approval for emergency cases only. The Insurer / RGJAY society reserves the right to cancel the Emerge ncy telephonic approval, if the provider fails to update the pre-authorization online within 72 hours of Emergency telephonic approval. The provider also agrees to perform the surgery / therapy obtained through telephonic intimation within 24 hours form the date and time of telephonic approval. The Provider also agrees to update the surgery/ therapy done for telephonic instructions online mentioning the date & time along with specific remarks and photographic evidences while updating the online preauthorization, starting from the telephonic intimations. (Refer Annexure-XXVII).
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Article 19: Transport of Patients 19.1 The Provider agrees to transport of bear the cost of transport charges (To & fro) incurred by the beneficiary and agrees to arrange the same at time of discharge and obtain acknowledgment from the patient accordingly. The Provider agrees to obtain signature of beneficiary on the acknowledgment sheet generated from the portal and upload the scanned copy to RGJAY Web portal. Article 20: Free food to patients 20.1 The Provider agrees to provide free food to the patients as envisaged in the package rates either through inhouse pantry or by making alternate arrangements like supplying from nearby canteen. Article 21: Discharge and Follow up 21.1 Intimation of the impending discharge of the Beneficiary need to be advised to RGJAY Assistance Counter at least one day before the discharge of the patient. 21.2 The discharge has to be done in the presence of MCO and Aarogyamithra concerned and update the details ONLINE. 21.3 At the time of Discharge the transportation cost to and fro has to be reimbursed to the Patient, if the Hospital has not provided the transportation. The acknowledgment of receiving the amount for transportation has to be generated from the RGJAY society portal and the signed copy has to be uploaded. 21.4 Discharge summary will be generated from the RGJAY society portal in a pre-printed stationary to be supplied. The Discharge summary will consist of all the treatment details of the Patient at the Hospital and the follow up regime for the Patient including consultation and medication. 21.5 All the patients must be provided with follow- up medicines after discharge by the provider as part of the package. 21.6 If the same Patient is coming back to the Hospital, the follow up derails have to be uploaded in the RGJAY society portal. 21.7 Satisfaction letter of the Patients has to be generated from the RGJAY society portal and the signed copy has to be uploaded. 21.8 The MCO & Aarogyamithra should counsel the patient for all the precautions to be taken for the post-operative care. 21.9 All patients who requite follow- up medicines will be advised by the provider to come back on 11th day of discharge for first follow0up mandatory. The date of first followup will be generated by the RGJAY society portal along with the discharge summary. 21.10 The subsequent follow-ups for the above cases will be as per the follow- up guidelines (Refer ANNEXURE-VI) 21.11 The Provider will agree to provide follow- up services for a period of ONE YEAR under the Scheme. 21.12 The provider will provide free post-transplant immunosuppressive therapy for a period of six months from date of surgery (1 st to 6th month), irrespective of agreement period for all cases of renal transplant within package. The provider will do cashless posttransplant immunosuppressive therapy for the remaining period of six months (7 th to 12th month) under RGJAY II. 21.13 The provider will agree to provide free post-surgical physiotherapy services, wherever required for the agreement period. Article 22: Billing Procedure / Checklist for the Provide r at the time of Patients discharge 22.1 It is admitted and agreed that the Provider is aware that this MOU has arisen for the purpose of implementation of the RGJAY Community Health Insurance Scheme (RGJAY I & II) intended for Below Poverty Line families in specified Districts of Maharashtra and accordingly the Provider will in no circumstance charge or seek any payment from the Beneficiary families but will look only to for indemnity, and that too
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only to the limits/ schedule of fees in respect of procedures referred to earlier and agreed to under this MOU. 22.2 Signature or the LTI of the patient / Beneficiary will be obtained on final hospital bills and the discharge form. 22.3 The provider will submit the following to Original discharge summary, original investigation reports. All original prescriptions, Procedure CDs MRI films, X -rays, Post-Operative slides with Biopsy report, 3 Photographs of the patient taken preoperative bedside, immediate post-operative showing operation wound and at the time of discharge, Case Sheet with Operation Notes Breakup of the bills (Room Rent, Investigations, Procedure charges & pharmacy receipt) etc. These are to be made available to for Claim payment, while submitting the bill. The copies of the discharge summary signed by the Beneficiary will be uploaded in the web. A summary of the bills raised will also be uploaded. 22.4 Letter of satisfaction from the patient should also be obtained and sent along with the bills to in prescribed format. 22.5 Provider should ensure that Chemo Therapy Drugs are physically administered to the Patients. Provider should produce bills by coating batch no. and attaching empty vials & ampoules with intact labels. 22.6 The Provider will have-an Officer designated as Billing Head in order to follow the process the online work flow. The provider agrees to submit the details of Billing Head as per the ANNEXUR XXIII. Article 23: Payme nt Terms and Conditions 23.1 Insurer agrees to pay all the eligible bills within 7 working days. Subject to submission of all supporting documents including post-operative investigations and reports as required online and the photocopies of daily progress report and ICU charts should be sent by courier. 23.1a The payments to the provider are made the Insurer after deducting Taxes (TDS) as per prevailing IT Rules, and accordingly Insurer will issue the Form No. 16A t the end of Financial Year. Provider hereby agrees to comply all the formalities required in fulfilling regulations of Income Tax Dept. (Refer ANNEXURE-XXVI) 23.2 The provider agrees to submit the core banking number IFSC code to the insurer to facilitate electronic fund transfer for settling the claims. (Refer ANNEXURE-XIX) 23.3 The Provider agrees to submit all the claims for the surgeries / Treatments performed within 60 days from the date of discharge of patient. 23.4 The provider agrees to perform Surgeries / Treatment within 30 days from the date of expiry of this agreement for all the Pre-authorizations obtained during the period and submits the claim as per clause 23.3 above. Article 24: Limitations of liability and inde mnity 24.1 The Provider will be responsible for all commissions and omissions in treating the patients referred under the scheme and will also be responsible for all legal consequences that may arise. Insurer /RGJAY society will not be held responsible for the choice of treatment and outcome of the treatment or quality of the care provided by the provider and should any legal complications arise and is called upon to answer the provider will pay all legal expenses and consequent compensation, if any. 24.2 The Provider admits and agrees that if any claim arises out of alleged deficiency in service on their part of on the part of their men or agents, then it will be the duty of the provider to answer such claim. In the unlikely event of Insurer being proceeded against for such cause of action and any liability was imposed on them, only by virtue of its relationship with the provider and then the provider will step in and meet such liability on their own. 24.3 Notwithstanding anything to the contrary in this Agreement, neither Party will be liable by reason of failure or delay in the performance of its duties and obligations
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under this Agreement if such failure or delay is caused by acts of God, Strikes, lockouts, embargoes, war, riots civil commotion, any orders of Governmental, QuasiGovernmental or local authorities, or any other similar ca use beyond its control and without its fault of negligence. 24.4 The Provider undertake for applicability of terms and conditions mentioned and in all the MOUs executed for all the phases in- lieu of this MOU. Article 25: Confidentiality 25.1 All the stakeholders undertake to protect the secrecy of all the data of Beneficiary families and trade or business secrets of and will not share the same with any unauthorized person for any reason whatsoever within or without or consideration. 25.2 The provider agrees to protect the confidentiality under this agreement and ensures not to recruit ex-employees of insurer anytime during this agreement and also for a further period of one year from the date of expiry of this an agreement. Article 26: Termination 26.1 Any deficiency in service by the empanelled hospitals (Provider) or noncompliance of the provisions of MOU will be scrutinized by the Empanelment & Disciplinary Committee (EDC) comprising of representative from the RGJAY society and Insurer and make deliberations to sus pend / de-list / stop payments or any other appropriate action based on the nature of the complaint against the Provider. The Provider shall abide by the deliberations made by the EDC and RGJAY society. Article 27: Jurisdiction 27.1 Any dispute arising of this MOU will be subject to arbitration as per Arbitration Act and subject to the jurisdiction of Maharashtra courts only. 27.2 Any amendments in the clauses of the Agreements can effected as an addendum, after the written approval from both the parties. Article 28: Non-exclusivity 28.1 Insurer reserves the right to appoint other Provider/s for implementing the packages envisaged herein and provider will have no objection for the same and vice-versa.
In witness thereof this agreement executed b y or on behalf of the parties on the day and year mentioned above. Signed and delivered by: Provider: Through its Managing Director / by Sri/Smt. ______________________________________ Sign _______________________________ In presence of Sri/ Smt. ____________________________________ Sign _______________ ____________________________________________________________________ Through its Chief Operating Officer Sri / Smt. ___________________________________ Sign ___________________________________ In presence of Sri / Smt ____________________________________Sign ______________
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Rider A
1 Resolution of dispute: In the event of any question, dispute or differences in respect of contract or terms and conditions of the contract or interpretation of the terms and conditions or part of the terms and conditions of the contract arises, the parties may mutually settle the dispute amicably. Arbitration:
If any dispute arises between the parties hereto during the subsistence of this Agreement of thereafter, in connection with the validity Interpretation implementation or alleged breach of any provision of this Agreement, the parties shall refer such dispute to their respective chairmen/CEOs for resolution. In the event that the chairmen/CEOs are unable to resolve the dispute within 30 days of it being referred to them, then either Party may refer the dispute for resolution to a sole arbitrator who will be Additional Chief Secretary / Principal Secretary Public Health and Family Welfare Department Government of Maharashtra, or, in the event that the parties are unable to agree on the person to act as the sole arbitrator within 30 days after any party has claimed for an arbitrators in written form, by three arbitrators, one to be appointed by each party with power to the two arbitrators so appointed, to appoint a third arbitrator.
3 4 5 The arbitration proceedings shall be carried out as per the Indian Arbitration and Concillation Act, 1996 and the rules made thereunder. Governing Language: English language version of the contract shall govern its interpretation. Applicable Laws: The contract shall be governed in accordance with the law prevailing in India, Act, Rules, Amendments and orders made theron from time to time. Indemnification: The contractor shall indemnify the purchaser against all actions, suit, claims and demand or in respect of anything done or omitted to be done by contractor in connection with the contract and against any losses or damages to the purchaser in consequence of any action or suit being brought against the contractor for anything done or omitted to be done by the contractor in the execution of the contract. Jurisdiction All the suits arising out of the contract shall be instituted in the court of competent jurisdiction situated in Mumbai only and not elsewhere. Saving clause No suits, prosecution or any legal proceedings shall lie against the Joint Director of Health Services (Procurement Cell), Mumbai or any person for anything that is done in good faith or intended to be done in pursuance of RFP.
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ANNEXURE-1 ATTACH ATTESTED COPY OF IRDA LICENSE

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ANNEXURE-2 EXPERIENCE IN GROUP HEALTH INSURANCE OF THE COMPANY IN INDIA

1 2008-09 1 2 3 2009-10 1 2 3 2010-11 1 2 3

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Signature & stamp of Insurance Agency

Signature & stamp of Insurance Agency

(ON BOND PAPER OF RS. 100)

BY THE INSURANCE AGENCY

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BY THE INSURANCE AGENCY

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Signature & stamp of Insurance Agency

All India (Numbers)

State ( Numbers) Gadchiroli Amravati

Head Office Zonal Offices Operating Offices

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Signature & stamp of Insurance Agency

PLAN FOR HEALTH CAMPS

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DETAILS OF EMPANELLED HEALTH FACILITIES WITH INSURERS

Gadchiroli Amravati, Nanded, Solapur,

Other Districts within Maharashtra

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ANNEXURE -11 ANY OTHER INFORMATION