PRADHAN MANTRI JAN AROGYA YOJANA

1. I
DR ANKITA PATEL
MD(RADIATION AND MEDICAL ONCOLOGY)
NABH COORDINATOR
FELLOW:NUH, SINGAPORE
FORTIS,GURUGRAM

2. AYUSHMAN BHARAT

6. क्या आपके पास आयुष्मान कार्ड है ?
इससे आपके इलाज़ में सुविधा होगी.
PM SWASTHYA CARD
CM SWASTHYA CARD

8. • 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.

9. 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

10. 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.

11. • PLEASE ADVICE SPECIFIC, LIMITED AND
BARE MINIMUM INVESTIGATIONS.

12. 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 .

13. • 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.

14. • 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.

15. • 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.

16. • 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.

21. 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.

22. • 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.

23. 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.

24. 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.

25. 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.

26. • 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

27. 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.

31. 8/31/2019 31APEX HOSPITAL