Project - How to provide cashless medical care to beneficiaries under the Scheme fee castro

trophic illnesses.
Objective of scheme - To Provide He Treatment under yojna for Emergencies, operation and
health care.
There are two types of yojna.
1. MYPJAY - Mahatma Jyatiba Jan Arogyaa Yojna
2. PMJAY - Prodhan-Mantri Jan Arogyaa Yojna
MYPJAY and PMJAY Yojana is flagship health insurance scheme of Government of
Maharashtra.
Scheme provides end to end Cashless Services for identified diseases.
The Package include-
1. Pre and Past - treatment diagnostics,
2. Consultations
3. Hospitals charges
4. Consumable and Medicines
How to Apply
1. Log in their official website
2. Enter your mobile Number and capture code given on the screen.
3. Enter OTP that is sent your registered mobile number.

 Eligibility of PMJAY and MYPJY

 Below Poverty line income less then families having less than one Lakh rupees per annum
 Yellow or orange Ration Card holders.
 Annapurna card
 White Ration card (only farmer)

District wise families are counted which is issued by the Government of Maharashtra
Policy is renewed by 1 year
BENEFICIARIES
Families Holding

 Yellow Ration cards (Below Poverty Line Families)

 Antyodaya Anna Yojana card
 Orange Ration cards (Above Poverty Line Families)
 Annapurna card
 Pink Ration Cards (Temporary Ration Card)
 Digital Ration card
 White ration card (Only Farmer/ Selected 14 District) issued by Maharashtra Govt...

OBJECTIVE OF THE SCHEME

1. To improve medical access of

 Below Poverty Line (BPL - Yellow Card Holders)

 Above Poverty Line (APL- Orange card Holders) families.

2. To provide Quality health care for identified specialty services requiring hospitalization for
surgeries through Network hospitals.

Critical Protocols Guidelines

1. Burns
2. Cardiology
3. Dermatology
4. ENT Surgery
5. General Surgery
6. Nephrology
7. Neurology
8. Neurosurgery
9. Polytrauma
10. Pulmonology
11. plastic surgery
12. Radiation oncology
13. General Medicine
14. Medical oncology
15. Surgical oncology
16. Gradtre-enterology.
Scheme shall provide coverage for meeting all expenses relating for to hospitalization

 Coverage up to 15 000/- (far MYPJY)

 Coverage up to 2, 59000/ (for renal transplant)
 Coverage up to 5, 00, 00/ (for PMJAY)

BASIC SUM INSURED

 Scheme shall provide coverage for meeting all expenses relating to hospitalization.
 Coverage up to INR 1, 50,000/- (per family on floater basis per year).
 Coverage up to INR 2, 50,000/- (for renal transplants).
 Procedures offered – Surgical & Medical procedures
 Total procedures covered till date are 971, covered systems: 30 systems
 121 / 971 procedures are eligible for 1 Year Follow-up services
 132 Procedures are reserved for Govt. hospital
 Private hospital can perform 839 procedure out of 971 procedure
 Covers Preexisting Diseases.

Empanelment Criteria
1. ICU facility facility with required staff.
2. Fully Equipped operation Theatre.
3. Medical and Surgical facilities.
4. Round the clock Diagnostic facilities
5. Separate Male and female General word
6. Ambulance Services.
7. Casualty / duty doctor.
8. Appropriate nursing staff
9. Minimum 50 inpatient medical beds.
10. Trained paramedics
PATIENT REGISTRATION - OVERVIEW
1. Any beneficiary contacting RGJAY officials to avail health insurance facilities offered by the
scheme is required to be registered in the module. Following are the four different modes of
referral of the patients:

 Health Camp
 PHC
 Customer Care
 Direct to Network Hospitals

2. The beneficiary should carry a Health Card /Ration Card while registering them at the network
hospital
3. Jeevandayee Patient Registration form is generated once the registration is done.
4. Information retrieve in the system will be registered and the patient will be forwarded to the
MCO for further diagnosis. Information not retrieve will be forwarded through enrollment
module.
E-PREAUTHORIZATION
1. E-Preauthorization is a process of taking approval before performing surgery/ therapy on an
Jeevandayee patient by a network hospital.
2. Preauthorization will help TPA doctors & Society doctors to view the details of the patient
eligibility card, patient condition, diagnostics performed, procedure required, treating doctor
details and how many times the patient has undergone surgery/ therapy under Jeevandayee or it
is the first time.
3. This will ensure a transparency between NWH & Insurer/TPA/Trust with regard to the
patients of Jeevandayee.
HEALTH CAMPS

 Health Camps are the main source of mobilizing the beneficiaries under the scheme.
 Health Camps are to be conducted in Taluka Head Quarters, Major Gram Panchayat and
Municipalities.
 MCCO will coordinate the entire activity and shall carry necessary Equipment’s, Network
Hospital Doctors, Para medical staff, one lady doctor, Screening enclosures, PHC Medical
Officers and PHC Aarogyamitra. (Primary Health Centre)
 Hospital shall follow the Camp policy of Rajiv Gandhi Jeevandayee Arogya Yojana Society.
 Society schedules Health camps
 MCCO should take the approval one month prior to the date of Health Camp.
 In order to qualify for the process of Pre-Auth and Claims the patient has to be a beneficiary
of the scheme and admitted as In Patient for a particular duration. Relevant documentations
related to the admission have to be maintained by the treating doctors to ensure eligibility of
claim being reimbursed.
 All the Pre-Authorization cases have to be closed with outward within 24 hours TAT. (for
both phase 1 & 11)

PACKAGE DETAILS
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,

1. One time transport cost by State Transport or second class rail fare (from Hospital to residence
of patient only)
2. 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.
CAMP ACTIVITIES
During camp Network hospital shall provide basic facilities to the beneficiaries attending the
camp
Facilities at Camp

 Providing shade for waiting patients by erecting shamiyanas / Tents

 Providing pedestal fans.
 Sitting arrangements for waiting patients by providing sufficient number of chairs
 Drinking water for patients
 Screening enclosures for patients
 Snacks
 Any other activity chosen by the hospital
CLAIMS

 When a patient has undergone surgery/therapy in a Network hospital, the treatment is

cashless to the patient but not to the Network hospital.
 Network hospital can claim for the treatment and the facilities provided to the beneficiary
through online under claims module.
 Claim appeal should be initiated within 20 Days of claim rejection.
 Claim appeal should be initiated within 20 Days of CMO rejection.

ONLINE CLAIM SETTLEMENT

1. The Insurance Company shall settle the claims of the hospitals online within 15 business
working days of receipt of
 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
2. The online progress of claim settlement will be scrutinized and reviewed by STATE
HEALTH ASSURANCE SOCIETY- SHAS
FOLLOW UP
 Network Hospital has to provide free follow up medicine up to 1 year from 11 th day of the
discharge for 121 procedures out of 971 procedures.
 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.
 If any white ration card holder approaches ARM kiosk, ARM should verify district whether
it fall under 14 farmer suicide prone districts.
 ARM should enroll and attach Ration card, 7/12 abstract and identity proof as per
requirement.
 If a beneficiary is not having his name mentioned in ration card and 7/12 abstract, then a
certificate mentioning beneficiary belongs to a farmer’s family from the nearest revenue
officer will be necessary.
 In case of any deficiency of document or in emergency condition, the ETI may be generated
this will be valid for a period of 7 working days. ETI declaration should be obtained as per
ETI SOP along with self-declaration.
 Declaration from beneficiary stating that no one from his family is working with Govt./ Semi
government and that their family is dependent on income of the farm land.
 For New born babies and 0-6 year children, existing guidelines will be applicable in addition
to 7/12 abstract of either of parents.
 As coverage of the white card holding farmers from 14 districts had included recently, due to
lack of awareness if they are approaching ARM or hospitals without proper documentation,
they should be counselled properly and if necessary ETI can be availed.

RUN-OFF PERIOD & POLICY EXPIRED CASES

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 20th November for 27 districts Phase-II. 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.
PRE CAMP ACTIVITIES
13 IEC ACTIVITIES – At least 6 are MANDATORY, Activity should start before 7 days
1. Pamphlet Distribution
2. Public Address System/ Mike announcements in Autos
3. Dandora/ beat of tom-tom
4. Playing Audio-Visual media (cassettes, Audio CDs and DVDs)
5. Scroll in local cable networks.
6. 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

E-PREAUTHORIZATION

 E-Preauthorization is a process of taking approval before performing surgery/ therapy on an

Jeevandayee patient by a network hospital.
 Preauthorization will help TPA doctors & Society doctors to view the details of the patient
eligibility card, patient condition, diagnostics performed, procedure required, treating doctor
details and how man times the patient has undergone surgery/ therapy under Jeevandayee or
it is the first time.
 This will ensure a transparency between NWH & Insurer/TPA/Trust with regard to the
patients of Jeevandayee.