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I
DR ANKITA PATEL
MD(RADIATION AND MEDICAL ONCOLOGY)
NABH COORDINATOR
FELLOW:NUH, SINGAPORE
FORTIS,GURUGRAM
AYUSHMAN BHARAT
क्या आपके पास आयुष्मान कार्ड है ?
इससे आपके इलाज़ में सुविधा होगी.
PM SWASTHYA CARD
CM SWASTHYA CARD
• PMRSSM would be at any of the empanelled
cashless & paperless hospitals.
• The beneficiaries shall not be required to pa...
The beneficiary shall be either be prescribed medical
drugs, directed for further diagnostics or
hospitalization.
Benefici...
For a beneficiary who has been suggested
diagnostics:
I. The beneficiary should avail the diagnostic facility within the
E...
• PLEASE ADVICE SPECIFIC, LIMITED AND
BARE MINIMUM INVESTIGATIONS.
For beneficiaries
requiring hospitalization:
• The standard template for pre-authorization will be filled by the
treating ...
• The PMAM shall select the medical package recommended
by the specialist doctor / MEDCO and upload the necessary
document...
• During the treatment period or post surgery, the PMAM
shall click another picture of the beneficiary / patient on
the ho...
• Post-discharge, the EHCP will provide the beneficiary with
relevant medication and diagnostics as per the package
for up...
• Post-discharge, the EHCP will provide the beneficiary with
relevant medication and diagnostics as per the package
for up...
Package Selection
• The operator will check for the specialty for which the hospital is
empanelled. Hospitals will only be...
• Certain packages as mentioned will only be reserved for Public EHCPs as
decided by the SHA. They can be availed in Priva...
Cardiology
• Pre-authorization remarks:
• Specific Pre and Post-op Investigations such as ECHO, ECG, pre/
post-op X-ray, l...
CTVS
• Pre-authorization remarks: Specific Pre and Post-
op Investigations such as ECHO, ECG, pre/ post-
op X-ray, post-op...
UROLOGY
• Prior approval must be taken for surgeries requiring use of
Deflux injection, Botox Injection, inflatable penile...
• Prior approval must be taken for all elective
Surgeries/Procedures. Although the following
packages, namely C-Section, H...
Certain Queries which are very
frequently coming up..
• Stamp and signature on each document
daily updation of
EACH patien...
8/31/2019 31APEX HOSPITAL
Ayushmaan Bharat Scheme
Ayushmaan Bharat Scheme
Ayushmaan Bharat Scheme
Ayushmaan Bharat Scheme
Ayushmaan Bharat Scheme
Ayushmaan Bharat Scheme
Ayushmaan Bharat Scheme
Ayushmaan Bharat Scheme
Ayushmaan Bharat Scheme
Ayushmaan Bharat Scheme
Ayushmaan Bharat Scheme
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Ayushmaan Bharat Scheme

  1. 1. I DR ANKITA PATEL MD(RADIATION AND MEDICAL ONCOLOGY) NABH COORDINATOR FELLOW:NUH, SINGAPORE FORTIS,GURUGRAM
  2. 2. AYUSHMAN BHARAT
  3. 3. क्या आपके पास आयुष्मान कार्ड है ? इससे आपके इलाज़ में सुविधा होगी. PM SWASTHYA CARD CM SWASTHYA CARD
  4. 4. • PMRSSM would be at any of the empanelled cashless & paperless hospitals. • The beneficiaries shall not be required to pay any charge for the hospitalization expenses. The benefit also includes pre- and post- hospitalisation expenses.
  5. 5. The beneficiary shall be either be prescribed medical drugs, directed for further diagnostics or hospitalization. Beneficiaries prescribed medical drugs and not requiring hospitalization will pay relevant consultation and drug charges if and as applicable
  6. 6. For a beneficiary who has been suggested diagnostics: I. The beneficiary should avail the diagnostic facility within the EHCP or from a EHCP empaneled diagnostic provider. II. The hospital will not collect any money from the beneficiary before the diagnosis and shall ensure that the empaneled diagnostic provider also does not collect any money from the beneficiary III. The beneficiary is informed of the amount of charges for diagnosis they may have to bear in case they are not hospitalized. Only in case of not being hospitalized the beneficiary would be required to pay the relevant charges for diagnosis.
  7. 7. • PLEASE ADVICE SPECIFIC, LIMITED AND BARE MINIMUM INVESTIGATIONS.
  8. 8. For beneficiaries requiring hospitalization: • The standard template for pre-authorization will be filled by the treating specialist doctor / MEDCO (medical coordinator). (Every EHCP may nominate a medical doctor who shall act as a coordinator between the PMAM and the treatment doctor) • The treating doctor / MEDCO will be responsible for providing the necessary documents (filled pre-authorization form, diagnostic reports, clinical notes etc.) to the PMAM • The PMAM shall click a picture of the beneficiary / patient on the hospital bed and upload the picture on the TMS portal .
  9. 9. • The PMAM shall select the medical package recommended by the specialist doctor / MEDCO and upload the necessary documents required for processing the pre-authorization request in the Transaction Management System. The PMAM shall also be responsible for handling any follow up queries from the ISA / Trust: • For packages requiring a pre-authorization from ISA, the request generated shall be approved by within a maximum time of 6 hours by the ISA / Trust. • For packages not requiring a pre-authorization from ISA, the request shall be approved automatically. However, there needs to be a pre-authorization filed and updated on daily basis. Subsequent pre-authorizations will be required as applicable if beneficiary needs to remain hospitalized for more than authorized period.
  10. 10. • During the treatment period or post surgery, the PMAM shall click another picture of the beneficiary / patient on the hospital bed and upload the picture on the TMS portal • Once the treatment is complete and the beneficiary is ready to be discharged, the PMAM shall collect the necessary documents such as the discharge summary (Attached as Annexure II) , clinical notes, medical scans etc. which will be required for filing claims. Additionally, the PMAM shall click another picture of the beneficiary / patient at the time of discharge and upload the picture on the TMS portal. A physical copy of discharge summary and other documents such as diagnostic reports etc. may also be provided to the patients.
  11. 11. • Post-discharge, the EHCP will provide the beneficiary with relevant medication and diagnostics as per the package for upto 15 days as applicable. The PMAM will be responsible for informing the beneficiary about these entitlements. • The PMAM will be responsible for collecting feedback from the beneficiary in a standard feedback form. The feedback shall be further studied by the SHA / NHA to improve upon the overall quality of care. • Also, to further improve the quality of care, the call centre shall shall also be assessing feedback by contacting a sample set of discharged beneficiaries.
  12. 12. • Post-discharge, the EHCP will provide the beneficiary with relevant medication and diagnostics as per the package for upto 15 days as applicable. The PMAM will be responsible for informing the beneficiary about these entitlements. • The PMAM will be responsible for collecting feedback from the beneficiary in a standard feedback form. The feedback shall be further studied by the SHA / NHA to improve upon the overall quality of care. • Also, to further improve the quality of care, the call centre shall shall also be assessing feedback by contacting a sample set of discharged beneficiaries.
  13. 13. Package Selection • The operator will check for the specialty for which the hospital is empanelled. Hospitals will only be allowed to view and apply treatment package for the specialty for which they are empanelled. • Based on diagnosis sheet provided by doctor, operator should be able to block Surgical or Non-Surgical benefit package(s) using PMRSSM IT system. • Both surgical and non-surgical packages cannot be blocked together, either of the type can only be blocked. • As per the package list, the mandatory diagnostics/documents will need to be uploaded along with blocking of packages. • The operator can block more than one package for the beneficiary. A logic will be built in for multiple package selection, such that reduced payment is made in case of multiple packages being blocked in the same hospitalization event.
  14. 14. • Certain packages as mentioned will only be reserved for Public EHCPs as decided by the SHA. They can be availed in Private EHCPs only after a referral from a Public EHCP is made. • Packages as indicated may have differential pricing for NABH and Non- NABH, for Hospitals running PG/ DNB Course, for rural and urban EHCPs and for EHCPs in aspirational districts as identified by NITI Aayog. • If a registered mobile number of beneficiary family is available, an SMS alert will be sent to the beneficiary notifying him of the packages blocked for him. • At the same time, a printable registration slip needs to be generated and handed over to the patient or patient’s attendant. • If for any reason treatment is not availed for any package, the operator can unblock the package before discharge from hospital.
  15. 15. Cardiology • Pre-authorization remarks: • Specific Pre and Post-op Investigations such as ECHO, ECG, pre/ post-op X-ray, label/ carton of stents used, pre and post-op blood tests (USG, clotting time, prothrombin time, international normalized ratio, Hb, Serum Creatinine), angioplasty stills showing stents & post stent flow, CAG report showing blocks (pre) and balloon and stills showing flow (post) etc. will need to be submitted/ uploaded for pre-authorization/ claims settlement purposes. The costs for such investigations will form part of the approved package cost. • It is prescribed as standard practice to use medicated stents (approved by FDA/DCGI) where necessary. Further the carton/ sticker detailing the stent particulars needs to be submitted as part of claims filing by providers. • - It is also advised to perform cardiac catheterization as part of the treatment package for congenital heart defects.
  16. 16. CTVS • Pre-authorization remarks: Specific Pre and Post- op Investigations such as ECHO, ECG, pre/ post- op X-ray, post-op scar photo, CAG/ CT/ MRI reports etc. will need to be submitted/ uploaded for pre-authorization/ claims settlement purposes. The costs for such investigations will form part of the approved package cost. • - It is also advised to perform cardiac catheterization as part of the treatment package for congenital heart defects.
  17. 17. UROLOGY • Prior approval must be taken for surgeries requiring use of Deflux injection, Botox Injection, inflatable penile prosthesis, urinary sphincter and metallic stents. • Further it is also mandated to get approval for all non- surgical conditions (involving evaluation/ investigation/ therapeutic management / follow-up visits) as indicated. • - For any procedure whose charges are Rs. 15,000 or higher, extra costs (in the sense other packages) cannot be clubbed/ claimed from the following: cystoscopy, ureteric catheterization, retrograde pyelogram, DJ stenting, nephrostomy – as they would form part of such packages costing Rs. 15,000 or higher as per the need.
  18. 18. • Prior approval must be taken for all elective Surgeries/Procedures. Although the following packages, namely C-Section, High Risk Delivery, Hysterectomy are primarily for government facilities, they are open to the private hospitals upon referral by government hospitals/Doctors. • Packages will include drugs, diagnostics, consultations, procedures, stay and food for patient. Medical conditions during pregnancy such at Hypertension, Diabetes etc are to be treated as per medical packages
  19. 19. Certain Queries which are very frequently coming up.. • Stamp and signature on each document daily updation of EACH patient is MANDATORY• Anaesthesia notes , OT notes mandatory • No patient can be discharged from ICU ,He has to be step downed to HDU followed by discharge. • If a patient is in ICU , and need ICU care on the next day, justification and proof of it is required. • They also ask for spo2 chart, temp chart, ventilator notes etc.
  20. 20. 8/31/2019 31APEX HOSPITAL
  • DrTahseenSiddiqui

    Jul. 3, 2020
  • IndhuAnu

    Jun. 16, 2020
  • DrAnkitaPatel

    Aug. 31, 2019

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