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Table 2 Guidelines on processes for hospital transaction

From: Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India

Guidelines Implementation status in Gujarat Implementation status in Madhya Pradesh
Preparatory Activities for State/ UT’s
 Availability of requisite hardware, software, and allied infrastructure required for PM-JAY scheme activities
 Medical Officer as Nodal Officer at EHCPa for PMJAY has been nominated Private hospitals (Except one in MP) had non-medical Nodal Officers
 Ensure appointment of Ayushman Mitra
 Ensure that a dedicated helpdesk for PM-JAY at a prominent place 5 of 7
 Availability of printed booklets at the helpdesk, which will be given to beneficiaries along with the PMJAY e-cards Х Х
 State Health Agency (SHA) shall set up team(s) to handle hardware and basic software support, troubleshooting, etc.
 Training of EHCP staff and Ayushman Mitras by the SHA/ Insurer
(Training is software centric)
Process for Beneficiary identification, issuance of e-card, and transaction for service delivery
 Operator/Ayushman Mitra identifies the beneficiary’s eligibility and registers patients √ (Private hospitals choosing not to issue card)
 TPIN (Telephonic Patient Identification Number) in case of emergency No TPIN; Patients admitted and registered next day
Package Selection
 Based on the diagnosis sheet provided by the doctor, the operator should be able to block the benefits package(s) using PM-JAY IT system
 Operator/Ayushman Mitra to initiate a request for pre-authorization to the insurer using PM-JAY IT system
 The decision on the request by the insurer latest by 6 h. If not, the request deemed to be approved by default 3–4 h Up 24 h
 Insurance Company/ Trust will provide the reasons for rejection
 The beneficiary or hospital can appeal through the grievance system No grievance system. Hospitals re-apply with required documents
Balance Check, Treatment, Discharge and Claim Request
 Based on the selection of package(s), the operator will check from the Central PM-JAY server if sufficient balance is available with the beneficiary to avail services. Low balance not encountered as the scheme is still new
 The operator fills the online discharge summary form and the patient will be discharged
 The beneficiary will be discharged with a discharge summary
Claim Payments and Turn-around Time
 The Trust/Insurer or the agency (Insurance Regulatory and Development Authority of India compliant only) appointed by it shall decide on the acceptance or rejection of any claim received from an EHCP. Any rejection notice issued by the Trust/Insurer or the agency to EHCP shall clearly state that rejection is subject to the EHCP’s right to appeal against the rejection of the claim. All hospitals shared that the rate of claim rejection is very low. However, they reported that SHA or insurer do not convey a reason for the rejection
 The process in relation to claim shall be carried out in such a manner that its completion (Turn-around Time, TAT) shall be no longer than 15 calendar days (irrespective of the number of working days). For claims outside the State, a time of 30 calendar days will be provided. Average TAT is around 90 days
  1. Source for guidelines: PMRSSM guidelines on processes for hospital transaction [16]
  2. aEHCP Empanelled healthcare provider