Ayushyman Bharat jan Aarogya yojana In Maharashtra - Updated.pptx

ABPMJAY AND MJPJAY TWO SCHEMES DETAILS

1. - 1800 233 2200 / 155 388 Free Quality Critical Care For Low Income Families AYUSHMAN BHARAT-PRADHAN MANTRI JAN AROGYA YOJANA (AB-PMJAY ) AND MAHATMA JYOTIBA PHULE JAN AROGYA YOJANA(MJPJAY ) Date 1 st July 2024 INTEGRATED

2. The objective of PMJAY and MPJAY is to reduce catastrophic health expenditure, improve access to quality healthcare, reduce unmet needs and reduce out of pocket healthcare expenditures for all residence of Maharashtra under the Scheme. These eligible beneficiary families will be provided coverage for secondary, tertiary and day care procedures (as applicable) for treatment of diseases and medical conditions through a network of Empaneled Health Care Providers (Network Hospitals- NWH). Overview & Objective of The Scheme

3. Old Scheme New Scheme Procedures MJPJAY-996 ,PMJAY-1209 1356 BOTH MJPJAY & PMJAY Govt. Reserved Procedures MJPJAY-134, PMJAY- 37 119 FOR BOTH MJPJAY & PMJAY Specialities 34 34 Follow-up Procedures MJPJAY-121 , PMJAY- 62 262 FOR BOTH MJPJAY & PMJAY Beneficiaries Category A, B & C + PMJAY (SECC) Category A, B ,C,D &E Basic Sum Insured MJPJAY -1.5 Lakhs (2.5 L for RT) PMJAY -5 Lakhs 5 lakhs FOR BOTH MJPJAY & PMJAY (1.5 lakh insurance & above 1.5 assurance) Renal Transplantation 2.50 lakhs 4.50 lakhs. Major Differences b/w Existing Policy Vs. New

4. Major Differences b/w Existing Policy Vs. New   Old Scheme New Scheme Grading A (100%), B (90%) & C (80%), For Single Specialty Grades A & B are applicable   A (100%), B (90%) & C (80%), For Single Specialty Grades A & B are applicable IT Operations SHAS SHAS Call Centre SHAS SHAS Empanelment Committee (EC) /Coordination, Empanelment and Disciplinary Committee(CEDC)- Chairman From SHAS From SHAS Insurer United India Insurance Co. Ltd. United India Insurance Co. Ltd. Final Authority of Enrollment TPA TPA and (SHAS In Rejected cases only ) Final Authority of TCM ADHS-SHAS ADHS-SHAS NWH’s Capping 1000 Max   1900 Health Camps 1 Camp per Month   1 Camp per Month TAT for NWH to submit claims after 11 th day of Discharge Pvt - Within 30 Days Pvt - Within 30 Days Govt.- Within -60days Govt.- Within -60days

5. BENEFICIARY SOCIETY - SHAS TPAs TECHNOLOGY – TCS PROVIDER - NWH INTEGRATED MJPJAY & PMJAY INSURER UIIC NHA SHAS STAKEHOLDERS

6. STAKEHOLDER National Health Authority (NHA) Is The Apex Body Responsible For Implementing India’s Flagship Public Health Insurance/Assurance Scheme Called “ Ayushman Bharat Pradhan Mantri Jan Arogya Yojana .” 1 Formulation Of Various Operational Guidelines Related To PM-JAY, Model Documents And Contracts To Ensure Standardization And Interoperability. 2 Take Any Decision Related To The Implementation Of The Scheme, Disbursement Of Grant-in-aid To The States And Issue Relevant Directions From Time To Time, As Required. 3 National Health Agency (NHA)

7. Text Text 05 04 03 02 01 Text The CEO is responsible for management, administration and control of the day to day affairs of the Mahatma Jyotiba Phule Jan Arogya Yojana in accordance with the rules, regulations, orders and instructions issued by the Governing Council of the State Health Assurance Society. Appointing and overseeing of the Insurance Company Activities for smooth functioning of the scheme. Objective- to conceptualize, implement, establish, provide, administer, modify & supervise directly or indirectly by mean of integrated MJPJAY and PMJAY This is formed to provide medical facilities to the beneficiaries identified by the Government of Maharashtra. SHAS Handling IT operations of MJPJAY web portal & Call Centre. Conduction IEC activities of the scheme like Advertisements in Digital & Print Media. Objective & Functionality of the SHAS

8. Objective & Functionality of the UIIC Solely responsible to implement the scheme as per terms & conditions mentioned in tender . Empanelling Hospitals & Claim Settlement Attending various committee meeting such as CEDC, CCCM etc Appointing & overseeing TPA’s activities. Assessment of Grades

9. Functionality of the TPA’s Solely Responsible To Implement The Scheme In The Districts Allotted By UIIC 1 Establishing & Maintaining Project Office (PO) And District Offices (DO). 2 Appointing Required Manpower At PO & DO Including Arms 3 Conducting Capacity Building Trainings To The TPA Staff & NWH’s. 4 Empanelling NWH’s As Per The Given Specified Guidelines. 5 Assessment Of Grades In Consultation With IC & SHAS. 6 Conducting Infrastructure & Medical Audits. 7 Processing Pre- auth & Claims Within Stipulated TAT. 8 E- Verification Of MJPJAY & PMJAY Beneficiaries Such As Enrolment & E-KYC 9 Attending Various Committee Meeting Such As CEDC, CCCM .. e tc 10 Grievance Redressal 11

10. Functionality of the NWH’s Provides the IT KIT for ARM 02 Appoints Dedicated Medical Coordinator (MBBS/BAMS/ BHMS/BDS) & Medical Camp Coordinator 03 Performs Surgery/Treatment 07 Provides Cashless Treatment to the Beneficiaries (In Patient-Discharge) 05 Provides the Place for KIOSK at Prominent Place like Near by Reception/Entrance 01 Free OPD Services to the Beneficiaries (Consultation & Investigations) 04 Provides Free Follow-up for Eligible Beneficiaries 08 Submits e-Preauthorization for Beneficiaries 06

11. A Category B Category C Category 1 ) Yellow Ration Card 2) Orange Ration Card (annual Income up to INR 1 lakh) 3) Antyodaya Anna Yojana Ration Card (AAY) 4) Annapurna Ration Card Ayushman card or white ration card or in absence of white ration card families with Domicile Certificate or Tahsildar’s letter will also be eligible for benefits of scheme on Assurance mode. (Including Government and Semi Government employees and their families) 1.Children of Government Orphanages, 2. Government Ashram Shala , 3. Female inmates of Government Mahila Ashram & 4. senior citizens of Government old age homes 5.Journalists & their dependent family members as per criteria of DGIPR, Maharashtra. 6.Construction workers and their dependent family members having live registration with Maharashtra Building & other Construction worker Welfare Board. Beneficiaries

12. D Category E Category C Category Road accident victims who are from outside Maharashtra and outside India who met an accident on the roads in Maharashtra and who are not covered under Category A, B & C are entitled to get health benefits of Rs 1 lakh per person per accident for 184 defined procedures. This will be covered under Assurance mode. Families in 865 villages of Belgaon , Karwar , Kalburgi and Bidar Districts of Karnataka border region. (8 lac families & 40 lac populations ) covered on assurance mode up to Rs . 5 lakhs. Antyodaya Food Yojana Priority Group Families and Annapurna Ration Card Holder Beneficiaries

13. All eligible families shall be identified with valid Yellow, Orange, Antyodaya and Annapurna ration card coupled with any Photo ID proof (as finalized by the Society). The following actions would be undertaken by the Insurer in case of the possible exceptional situations: CATEGORY A - IDENTIFICATION . In Case of new born babies Any child up to 6 years of age whose name is not there in the ration card will be considered as beneficiary provided the parents produce valid Birth certificate issued by local self Govt. authorities like Gram Panchayat , Municipal Council, Municipal Corporation or Delivery Discharge Card and photo of the Baby with the father or mother and any of the prescribed photo id proof of either the father or mother Beneficiary approached NWH with temporary ration card Accept and enroll the card Ration card is available in Torn manner If name and ration card number is not visible then to be rejected. If beneficiary submits photo copy of the ration card and if it matches with original ration card then enrolment should be approved Spelling mismatch in name with that mentioned on ration card and photo identity proof To be accepted if it is authorised by a certificate from the concerned Talathi with attested photo of the beneficiary stating name mentioned at the time of registration and actual name on ration card & photo identity proof are of the same person. Complete mismatch of name on ration card & photo identity proof To be accepted 01 02 03 04 05 Sno . Scenarios of ration cards available Acceptance Criteria

14. CATEGORY A - IDENTIFICATION . Beneficiary brought copy of original ration card / certificate from Tehsildar and photo copy of photo identity proof Any new family member name added recently To be accepted and enrolled. On front page of ration card Male is shown as Head of Family and on last page Female If two (2) head of the family found on ration card To be accepted and enrolled. Unit number on front page of ration card not matching with number of persons listed on last page. If name and ration card number is not visible then to be rejected. If beneficiary submits photo copy of the ration card and if it matches with original ration card then enrolment should be approved . A certificate from the concerned Talathi that the original card was issued to the beneficiary Beneficiary brought only photo copy of the ration card, no original card available To be accepted if it is authorized by a certificate from the concerned Talathi with attested photo of the beneficiary. To be accepted and enrolled. 06 07 08 09 10 11 Sno . Scenarios of ration cards available Acceptance Criteria 12 To be accepted and enrolled after confirming the name. Digitized ration card downloaded from Mahafood portal

15. CATEGORY B - GUIDELINES FOR TAHASILDAR CERTIFICATE HOLDERS AND DOMICILE CERTIFICATE Ayushman card or white ration card or in absence of white ration card families with Domicile Certificate or Tahsildar’s letter will also be eligible for benefits of scheme on Assurance mode. (Including Government and Semi Government employees and their families). Aadhaar Card would be insisted upon as the identification document and in the absence of Aadhaar card / number; any document which is accepted for issuance of Aadhaar card will be accepted. The list of valid photo identification documents given above against Category A would also be applicable for Category B. For Govt. employees, a self-declaration stating that they are not availing any other Mediclaim / medical reimbursement scheme for Govt. employees/CGHS and other medical reimbursement / cashless schemes of GoM / GoI is also required.

16. CATEGORY B - GUIDELINES FOR TAHASILDAR CERTIFICATE HOLDERS AND DOMICILE CERTIFICATE To generate the new Tahsildar id and Domicile Certificate Arogyamitra should enter the location details of beneficiary and click on Generate Id button. Original Copy of Tahsildar Certificate shall be submitted to Arogyamitra and Xerox copy of same shall be given to beneficiary with Enrollment id and unique system generated Tahsildar Certificate Id. To add family members in existing or already enrolled beneficiary under Tahsildar certificate category ARM shall enter the beneficiary location details and unique system generated Tahsildar certificate Id which will be available on Xerox copy of Tahsildar certificate and click on search button. The Unique system generated Tahsildar Certificate Id will be used while adding or enrolling other/remaining family members from the same family.

17. Eligibility of beneficiaries shall be decided on the basis of Ayushman card or identity card issued by respective head of the organization or any other identification mechanism as decided by the State Health Assurance Society (SHAS). The list of valid photo identification documents given below against Category A would be applicable for Category C also. For accredited journalists, beneficiary will be identified on the basis of identity card issued by Director General of Information & Public Relations (DGIPR)` For Construction workers, beneficiary will be identified on the basis of identity card issued by Maharashtra Construction & other construction welfare board along with photo identity of family member attested by Government Labour Officer of the department at district level. Aadhaar Card would be insisted upon as identification document and in absence of Aadhaar card / number; any document which is accepted for issuance of Aadhaar card will also be accepted. 01 02 03 04 05 CATEGORY C- IDENTIFICATION

18. Road traffic accident victims from outside Maharashtra and outside India who met with an accident on roads in Maharashtra and who are not covered under Category A, B & C will be identified by a geo tagged photo of the patient in the hospital, copy of the letter of information to be issued by the hospital to the police regarding the road accident and victim’s Aadhaar Card or Voter ID or Pan Card or Passport whichever is available for identifation CATEGORY D- IDENTIFICATION

19. Eligibility of beneficiary will be verified through Antyodaya Anna Yojana ration card, Annapurna ration card and Priority household ration card issued by competent authority of Karnataka Government. Identification of beneficiary will be done through Aadhaar Card. In absence of Aadhaar card / number; 12 identity proofs as mentioned in Category A will also be accepted. Self-declaration in the prescribed format is mandatory CATEGORY E - IDENTIFICATION

20. LIST OF VALID ID PROOFS TO BE ACCEPTED ALONG WITH VALID ORANGE, YELLOW, ANTYODAYA & ANNAPURNA RATION CARD

21. SUM INSURED Rs.5,00,000/- per annum per Family A) For The Beneficiaries of Maharashtra : 1.5 Lakhs would be provided through Insurance mode and Remaining 3.5 Lakhs would be provided through Assurance Mode (SHAS) B) For The Beneficiaries of other States : Rs.5,00,000 /- would be provided through Assurance Mode.

22. KIDNEY TRANSPLANT Sr No Procedure Cost 1 Renal transplantation 1,50,000 2 AV fistula 20,000 3 Doner's Nephrectomy 50,000 4 Recipient Investigations such as Blood investigations, HLA typing, CT scan, Micturating Cystourethrogram , 45,000 Retrograde Urethrogram etc. 5 Donor’s Investigations Blood investigations, HLA typing, CT Angiography 45,000 6 Dialysis after Renal transplant (12 weeks) if needed as per Nephrologist’s remarks 40,000 7 Immunosuppression therapy for every year as per advice of Nephrologist if required - 1,00,000 Grand Total 4,50,000

23. IDENTIFIED SPECIALIZED CATEGORIES

24. PACKAGE DEFINITION Bed charges in General ward The package rates will include : Cost of Surgical Appliances Medicines and Drugs . Surgeons, Anesthetists Cost of Prosthetic Devices, Implants, X-Ray & Diagnostic Tests Medical Practitioner, Consultants fees Food to inpatient One time transport cost by State Transport or second class rail fare (from Hospital to residence of patient only) Anesthesia, Blood, Oxygen O.T. Charges Nursing and boarding charges MJPJAY & PMJAY In other words ENTIRE COST of treatment for patient from the date of reporting to his discharge from the hospital and medicines for 10 days after discharge.

25. Appendix 19 Different TATs (Turn Around Times) under applicable scheme Sr No Activity TAT 1 Pre-authorization decision 06 Hours 2 Preauthorization approved Perform Medical or Surgical procedure within 20 days by Private and within 40 days by Public Hospitals 3 Pre-authorization pending 7 days 4 Emergency telephonic or Online intimation in case of no documents 5 working days 5 Emergency telephonic or Online intimation in case of no documents in case of change or addition of surgical package which falls in scheme Six hours of completion of Surgery or procedure 6 Claim submission Within 30 days from 11th day of discharge of patient for Private Hospitals Within 60 days from 11th day of discharge of patient for Public Hospitals 7 Claim decision for claims and follow up claims Within 15 working days from date of last submission of document. TAT will not be applicable in following circumstances 1. If all claims of Hospital are on hold as disciplinary action. 2. If particular claim is on hold for resolution of Grievance. 8 Treatment schedule update or Surgery update or discharge update Discharge update within 5 Business days after discharge or Transfer or death or DAMA of patient 9 Follow up claims for Hospitals Within 20 days from date of follow up for Private and within 40 days from date of follow up for Public Hospitals 10 Grievances 15 days 11 Claims outstanding (Not submitted) Within 30 days from 11th day of discharge of patient for Private Hospitals Within 60 days from 11th day of discharge of patient for public Hospitals 12 Issue tracker and flagged cases by TPA IT Team 10 days. Changes may be made in portal at time of resolution 13 First appeal to CMO Within 20 days of appeal 14 Second and last appeal to CCC Within 20 days of appeal 15 Procedure to be done after raising of ETI 12 Hours 16 Raising of Claim query Within 72 hrs after claim submission

26. EMPANELMENT CRITERIA, E-APPLICATION PROCESS NEIGHBORING STATE Targeted NWH’s 1900 Multi Specialty 30 Minimum Bed Capacity Provision of Empanelling Neighboring State NWH’s Stand Alone Dialysis Centre’s Single Specialty Max .Beds Reserved for MJPJAY/PMJAY Beneficiaries 25% <, 1)ENT 2)Ophthalmology 3)Orthopedic & Poly Trauma 4)Neonatal & Pediatric Medical Management <, 5)Pediatric Surgery 6) Oncology (preferably medical, surgical & radiotherapy at one place) 7)Burns 8)Nephrology (Maintenance Hemodialysis)) Only for 8 identified specialties 20 Minimum Bed Capacity Multi Specialty (Tribal/Aspirational Districts) 10

27. ADEQUATE FACILITIES TO BE PROVIDED BY NWH Separate Male & Female General wards. Medical & surgical facilities Round the clock Diagnostic facilities. (In house diagnostic center or it should be Tie-up with nearby diagnostic center) Fully equipped Operation theatre. Post OP ward with ventilator and other required facilities. ICU facility with required staff. Casualty / duty doctor / appropriate nursing staff. Fully qualified doctors of modern medicine should be physically in charge round the clock. Availability of qualified / trained paramedics. Round the clock Blood Bank facilities either In-House or Tie-up facility Ambulance services Maintaining complete record on day-to-day basis.

28. E-Application Infra-Audit (NABH Standards) District Coordinator-SHAS & District Head-TPA GOVT OFFICERS (CS,DHO,THO) & NWH OFFICER Co-ordination, Empanelment and Disciplinary Committee. (CEDC) Chairman-CEO SHAS Dy.CEO ,ADHS & CMC Empanelment Team-SHAS Representatives of IC Co. Representatives of TPA Co. Grading & Specialties given to the NWH) ( Based on e-empanelment application, current score of audit) Final Decision of CEDC Empanelment of Hospitals EMPANELMENT APPLICATION FLOW

29. FACILITIES TO BE PROVIDED BY NETWORK HOSPITAL (NWH)

30. ENROLLMENT FLOW

31. PATIENT REGISTRATION FLOW

32. ETI Hospital raised ETI request from MCO id and request will be approved by TPA executive.   The provider agrees to obtain Emergency Approval for emergency cases only. The Insurer /TPA reserve the right to cancel the Emergency Telephonic approval, if the provider fails to update the pre-authorization online within 5 business days (excluding Public Holydays) of Emergency telephonic approval taken. Should perform surgery/therapy obtained through telephonic intimation within 12 hours from 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 pre-authorization, starting from the telephonic intimations.

33. UPDATING OF OUTPATIENT/INPATIENT STATUS OF REGISTERED PATIENTS Once the patient is registered by Aarogyamitra it is the responsibility of MCO will update whether patient is OP/ IP after the investigations are completed. Therapy/surgery should happen only after the preauth approval. 01 04 OP/ IP updation has to be done by MCO in his/her login. For OP cases Out patient Prescription form will be given to patient and no medicines are provided to the patient in other word in case of OP consultation and investigation are free 05 02 When MCO updates the patient as IP, if surgery/ therapy are required, e-preauthorization should be raised for the patient. 03 06

34. OP/IP CONVERSION PROCESS (MCO)

35. WORK FLOW OF THE SCHEME AT NETWORK HOSPITAL Patient Can Reach Network Hospital From Various Routes Elective Cases Emergency Cases Emergency Telephonic Approvals Patient Registration Medical Consultation Updating OP/IP Status Outpatient Patient Goes With Prescription Inpatient Patient-on-bed E-preauthorization Preauth Approval Surgery/Therapy Discharge Follow-up Enrollment Claims Approved Claims Processed For Payment Claim Appeal Provision For Rejected Claim ONLY FOR ETI

36. E-PREAUTHORIZATION

37. All the Pre-Authorization cases will be processed within 6 hours and Claims will be settled within 15 working days. CHECK LIST OF PRE-AUTH & CLAIM DOCUMENTATION ENROLMENT ON BED PHOTO OF PATIENT MJPJAY FINAL BILL RATION CARD PRE-AUTH FORM & DIAGNOSTICS REPORTS SATISFACTION LETTER IID PROOF COUNSELING & CONSENT FORM TRANSPORT COST ACKNOWLEDGEMENT PATIENT REGISTRATION DISCHARGE PHOTO POST TREATMENT EVIDANCES IN PATIENT CASE REGISTRATION DISCHARGE SUMMARY

38. 38 Stage -I PREAUTHORIZATION WORK FLOW

39. 39 Stage -II

40. Stage -III

41. Claims & Claim TATs

42. Claims Submitted by NWH Claims in Process Approved by TPA Kept Pending by TPA Rejected by TPA Send for Insurer scrutiny Sent back to CMO of TPA A/C Verified by Insurer Approved Rejected A/C Re-verified by insurer Claim sent for Payment by insurer Bank Claim Paid Rep. Claim Appeal Claims Doctor Pending Updated Approved Rejected UIIC Claim sent for Payment by insurer Bank Claim Paid CLAIMS WORKFLOW- Insurance Mode Stage -I

43. Claim Doctor Reject Repudiated Claim Appeal Initiated CMO Login Approve Reject Pending CMO Approved (Repudiated) CMO Rejected (Repudiated) CMO Pending (Repudiated) MCO Updates CMO pending Updated (Repudiated) Repudiated Claim Appeal Initiated by NWH to CCC Approve Reject MCO Login – Initiate Repudiated Claim appeal (should be initiated within 20 day of Claim Rejection ) CMO Approved (Repudiated) Final decision Final decision NWH should appeal for CCM within 20 Days of CMO rejected Stage -II CLAIM APPEAL MODULE WORKFLOW Process within 7 business days appeal raised by Hospital CCC Case to be Processed within 7 business days of 2 nd level of appeal raised by Hospital

44. TO BE CONTINUED CLAIM WORKFLOW- HYBRID MODE MCO CLAIM EXECUTIVE (TPA) CLAIM DOCTOR (TPA) PENDING APPROVED REJECTED SHAS CLAIM DOCTOR PENDING APPROVED REJECTED SHAS CMC PENDING APPROVED REJECTED ADHS THIS ROLE IS INTENDED TO APPROVE ONLY INSURANCE AMOUNT THIS ROLE IS INTENDED TO APPROVE ONLY ASSURANCE AMOUNT PENDING APPROVED REJECTED

45. ADHS APPROVED ACCOUNT OFFICER (INSURANCE) GM PAYMENT(INSURANCE) CLAIM PAID CLAIM REJECTED BY BANK SHAS FA DY CEO (TRUST) CLAIM PAID CLAIM REJECTED BY BANK CLAIM END INSURANCE PAYMENT ASSURANCE PAYMENT VERIFY VERIFY

46. The cases for which pre-authorization is given before the end of policy period or termination of the Insurer should be operated or treated within one month of date of pre-authorization. The treatment update, discharge update and claim submission should be done within one month from date of discharge. In case of exit of Insurer as per the terms and conditions of the RFP, it is binding upon the Insurer to settle the payments of all claims raised till the end of the day ( EoD ) of exit. 1 2 3 Treatment @ NWH’s Claims Submission Claims Settlement “Run-Off Period” will be one month after the expiry of the policy period or termination of the Insurer. Following should be done during the ” Run –Off Period ” :- RUN-OFF PERIOD

47. MCO CLAIM EXECUTIVE SHAS TPA CLAIM DOCTOR SHAS CMC SHAS CLAIM DOCTOR ADHS SHAS FA SHAS DY CEO CLAIM PAYMENT PENDING PENDING PENDING CLAIM WORKFLOW- ASSURANCE MODE PENDING

48. Network Hospital has to provide free follow up medicine up to 1 year from 11 th day of the discharge for 262 procedures out of 1356 procedures. For follow-up procedure NWH should provide Free consultation Free investigation Free Medicine Network hospital can claim for the benefits/facilities given to the beneficiary under follow up module. The claims have to be submitted in 4 installments. FOLLOW UP

49. DISCHARGE UPDATE MCO FOLLOWUP DONE MCO CLAIM EXECUTIVE VERIFIED CLAIM DOCTOR (FOLLOWUP) SENT FOR APPROVAL FOLLOWUP EXECUTIVE CLAIM INITIATED AROGYMITRA CLAIM DOCTOR APPROVED ACCOUNT OFFICER CLAIM DOCTOR REJECTED NA CLAIM DOCTOR PENDING MCO ACCOUNT VERIFIED GM PAYMENT SENT FOR PAYMENT BANK CLAIM DOCTOR PENDING UPDATED CLAIM DOCTOR GM ACCOUNT SENT BANK TO CLAIM DOCTOR CLAIM DOCTOR REJECTED GM PAYMENT PAID BANK ACKNOWLEDGEMENT GM PAYMENT Follow –Up Claims Work Flow

50. HEALTH CAMPS

51. There are three main activities for effective conduction of camps Pamphlet Distribution Public Address System/ Mike announcements in Autos Dandora / beat of tom-tom Playing Audio-Visual media (cassettes, Audio CDs and DVDs) Scroll in local cable networks. News/Advertisements in local dailies 7.Posters 8.Banners 9.SHG meetings 10.Village meetings 11.Exhibits on hygiene, general health, prevention of communicable diseases etc. 12.Exhibits on early detection and prevention of chronic diseases 13.Any other activity chosen by the hospital IEC Activities HEALTH CAMPS-ACTIVITIES

52. Sr. No. Activity Amount allocated in Rupees. Private Hospital Govt. Hospital 1 IEC Activity 1500 3000 2 Basic necessities to patients such as Shamianas , Chairs, Water, Fans, Snacks etc. 1500 3000 3 Providing common drugs to the patients as indicated in the list 1500 3000 4 Incentive to Government Medical Officers 500 1000  Total 5000 10000 3-5 hospitals jointly conducting Health Camps will be referred as Mega Health Camps (MHC) E very NWH needs to participate in at least 1 MHC every quarter . There should be 1 MHC in each taluka of the district every quarter (covering entire district in 3 months). Reimbursements will be done up to Rs . 15000 per hospital under MHC PHC Medical Officer is to be given an incentive of Rs. 250/- per camp. If in a single camp two medical officers are participating the network hospital shall pay incentive of Rs.250/- to each medical officer. In the event of Joint camps hospitals shall equally share the incentive amount and give a total incentive of Rs.250/- only to the Medical Officer if a single medical officer has participated. If there are more medical officers participating in a camp each medical officer shall be paid an incentive of not over Rs. 250/- on sharing basis by hospitals . HEALTH CAMPS INCENTIVES BREAK UP

53. MCCO TPA DISTRIC HEAD SHAS DISTRICT COORDINATER CANCEL WITH REASON MCCO SEND FOR REIMBURSEMENT APPROVED SENT BACK FOR CANCELLATION WITH REASON PRI-CAMP Approval Level POST-CAMP Claim Level Preferred date of camp, venue & proposal of camp Verify the details filled by NWH Final verification and Approval HEALTH CAMPS ONLINE WORKFLOW TO BE CONTINUED

54. HEALTH CAMP CLAIM EXECUTIVE VERIFY CLAIM EXECUTIVE CLAIM EXECUTIVE PENDING AT CLAIM LEVEL HEALTH CAMP MONITORING OFFICER MCCO POST-CAMP Claim Level CLAIM EXECUTIVE PENDING UPDATED AT CLAIM LEVEL CLAIM APPROVED BY HEALTH CAMP MONITORING OFFICER HEALTH CAMP MONITORING OFFICER PENDIGN AT CLAIM LEVEL MCCO GM OPERATIONS HEALTH CAMP MONITORING OFFICER PENDIGN UPDATED GM OPERATION PENDING MCCO GM OPERATION PENDING UPDATED ADHS HON. CEO FINANCIAL ADVISOR HON. DY CEO SEND BACK ACCOUNT REVISION PENDING APPROVE VERIFICATION TAB PENDING APPROVE PENDING APPROVE APPROVE REVISION OF AMT. TAB FINAL APPROVAL AUTHORITY TAB FOR ENTIRE PROCESS VIEW REVISION OF AMT. TAB

55. Grievance is a concern, problem or complaint of beneficiaries with regard to MJPAY services by Network Hospitals. TYPE OF GRIEVANCE Collection of Money by Network Hospital Denial of Admission Delaying the Treatment Conversion from non MJPJAY to MJPJAY Post operative complications Discharge Related Grievances Death Related Issues Negligence by Network Hospital Follow up Medicine Transportation cost not provided News Papers. Feedback received for CM Letters from patients. Phone calls Field team observation during daily visit to NWH/ vigilance report Patients / Attendants visiting the Head office. From Other departments. Public opinion posted in the Web site. E-Mails SOURCES OF GRIEVANCE GRIEVANCE –SOURCE & TYPE

56. Grievance Workflow

57. FEEDBACK MECHANISM Chief Ministers Voice Call Services to the Beneficiaries Out Bound calling to the discharged patients to know the feedback on the services provided. Social audit -Chief Minister Feedback Letters SMS gateway: SMS are sent to beneficiaries at 8 trigger points to inform about Registration, Preauth Approval, discharge & follow up etc . 58

58. FLIED TPA HIERARCHY

59. SHAS FLIED HIERARCHY

60. Thank You