memorandum of understanding (mou) - alankit healthcare · memorandum of understanding (mou) ......

Memorandum of Understanding (MOU)

Compiled By GI Council

Provider No.

MEMORANDUM OF UNDERSTANDING (MOU)

This Agreement made at ______ on this ___day of _______2016,

BETWEEN

_____________________________insurance company having its registered office at______

______________________and duly registered with IRDA under the Insurance Act, 1938

bearing licence no_____ hereinafter called the “Insurer” of the ONE PART. (The wordings

need a check)

AND

_______________________________________________________________________HOSP

ITAL/ NURSING HOME, owned and run by ____________________________________________________________________ being a

Registered public charitable Trust / private body / individual having its office at _________________________________________________________________________here

inafter referred as “Network Provider” (which expression shall unless it be repugnant to the

context or meaning thereof shall mean and include the persons for the time being and from time

to time constituting the said private organization /Trust, survivors or survivor of them) of the

Second Part.

AND

Third Party Administrator licensed by the Insurance Regulatory and Development Authority

under the Third Party Administrator - Health Services Regulation 2001( name, address, IRDA

License number as per list attached )

(hereinafter referred to as the “TPA /TPAs” which expression shall, unless repugnant to the

context or meaning thereof, be deemed to mean and include its successors and permitted assigns)

of the Third Part.

(“The Insurer” , “Network Provider” and the “TPA” are individually referred to as a “party”

and collectively as “parties”)

WHEREAS

1. The Insurer has agreed to provide health insurance to the individuals / group members

(hereinafter called “the Beneficiaries”)

2. The Network Provider agrees to extend medical facilities and treatment to the individuals / group members (hereinafter called “the Beneficiaries”) who require medical treatment and are duly covered under the Health Insurance policies issued by



the Insurer. 3. TPA a Third Party Administrator licensed by the Insurance Regulatory and Development

Authority under the Third Party Administrator - Health Services Regulation 2001 under License No…….. and having its registered office at ………………………………. Will be administering the health policy services of the provider on behalf of insurance companies

4. The Provider has accepted the offer made on the terms and conditions hereinafter appearing

NOW THIS AGREEMENT WITNESSETH AND IT IS HEREBY AGREED BY AND BETWEEN THE PARTIES HERETO AS FOLLOWS: - Clause 1: Standard Definitions & Interpretation

The terms and expressions appearing in this agreement shall have the meanings for the purpose

of this Agreement as defined under the Insurance Regulatory and Development Authority (

Health Insurance ) Regulations, 2016 and/ or the Guidelines on Standardization in Health

Insurance and Amendments thereto issued by IRDA. .

Clause 2: Warranties by Insurer

1. Insurer under this MOU is obligated to pay to the Provider (for the necessary medical treatment given to the Beneficiary provided the Provider has fulfilled all the necessary conditions as mentioned)

2. This agreement is signed by a person duly authorized by insurer and all the terms and

conditions contained in this agreement are binding on the Insurer.

3. The Insurer will deduct the TDS or any applicable taxes as per law from time to time while settling the bills. If any exemption is available to the provider they must inform the insurer in advance.

Clause 3: Identification of Beneficiary

1. The beneficiaries will be identified by the Network Provider on the basis of ID cards

issued to them bearing the logo and the title of the Insurer/TPA.

2. For the ease of beneficiary, the Network Provider shall display the recognition and

promotional material, network status and procedures for admission, supplied by

Insurer/TPA at prominent location, preferably at the reception and admission counter

and Casualty/Emergency departments. The Network Provider also needs to inform their

reception and admission-facilities regarding the procedures of admission and obtaining

pre-authorization

3. It shall be the responsibility of the provider to identify the beneficiary and mandatorily

take a photocopy of the ID card, to be submitted later with the bill or to keep as proof of

the beneficiary being treated. If beneficiary card is not available with the Insured for the



purpose of identification Network Provider can also collect Government Approved

photo ID cards such as Driving License, Passport, Aadhar Card, Election Card or PAN

Card. (Also would cover AMD ) In case of infant Children identification card of the

Insured parent would be accepted..

4. In the event of the Provider, bona fide, believing that the identity card or the

authorization letter is not genuine then the Provider shall contact TPA / Insurer and

address the same.

Clause 4: Scope of services provided by the Network Provider

Cashless facility admission procedure:

The procedure to be followed for providing cashless facility shall be:-

4A. Pre-authorization Procedure- Planned Admissions:

1. Request for hospitalization shall be forwarded by the provider immediately after

obtaining due details from the treating doctor /beneficiary in the pre-authorization

form prescribed i.e. “request for authorization letter” (RAL) as per Annex-I (this

form may change from time to time which will be informed, accordingly). The RAL

shall be sent along with all the relevant details in the electronic form to the 24-hour

authorization /cashless department of the insurer or its representative TPA along

with contact details of treating physician and the insured. The insurer’s or its

representative TPA’s medical team may consult the treating physician or the

insured, if necessary.

2. If the treating physician identifies any disease/ailment/illness/condition as pre-

existing, the treating physician shall record it and also inform the insured

immediately.

3. In the cases where the symptoms appear vague / no effective diagnosis is arrived at,

the medical team of the insurer or its representative TPA may consult with treating

physician /insured, if necessary.

4. The RAL shall reach the authorization department of insurer or its representative

TPA 7 days prior to the expected date of admission, in case of planned admission.

5. If “clause 4”above is not followed, the clarification for the delay needs to be

forwarded along with the request for authorization.

6. The RAL form shall be dully filled with clearly mentioning Yes or No and/or the

details as required. The form shall not be sent with nil or blanks replies.

7. The guarantee of payment shall be given only for the medically necessary treatment

cost of the ailment covered and mentioned in the request for hospitalization. Non



covered items i.e. non-medical items which are specifically excluded in the policy,

like Telephone usage, food provided to relatives/attendants, Provider registration

fees etc shall be collected directly from the insured. Indicative list of inadmissible

items provided as per Annex-II

8. The authorization letter by the insurer or its representative TPA shall clearly

indicate the amount agreed for providing cashless facility for hospitalization.

9. In the event of the cost of treatment increasing the agreed amount, the provider may

check the availability of further limit with the insurer or its representative TPA.

10. When the cost of treatment exceeds the authorized limit, request for enhancement of

authorization limit shall be made immediately during hospitalization using the same

format as for the initial preauthorization. The request for enhancement shall be

evaluated based on the availability of further limits and may require to provide valid

reasons for the same. No enhancement of limit is possible after discharge of insured.

11. Further the insurer shall accept or decline such additional expenses within a

maximum of 24 hours of receiving the request for enhancement. Absence of

receiving the reply from the insurer within 24 hours shall be construed as denial of

the additional amount.

12. In case the insured has opted for a higher accommodation / facility than the one

eligible under the policy, the provider shall explain orally the effect of such option

and also take a written consent from the insured at the time of admission as regard

to owing the responsibility of such expenses by the insured including the

proportionate expenses which have a direct bearing due to up gradation of room

accommodation/facility. In all such cases the insurer shall pay for the expenses

which are based on the eligibility limits of the insured. However provider may

charge any advance amount/security deposit from the insured only in such cases

where the insured has opted for an upgraded facility to the extent of the amounts to

be collected from the insured.

13. Insurance company guarantees payment only after receipt of RAL and the necessary

medical details. The Authorization Letter (AL) shall be issued within 48hours of

receiving the RAL.

14. In case the ailment is not covered or given medical data is not sufficient for the

medical team of authorization department to confirm the eligibility, insurer or its

representative TPA can deny the authorization.

15. Authorisation letter [AL] shall mention the authorization number and the amount

guaranteed for the procedure.

16. In case the balance sum available is considerably less than the cost of treatment,

provider shall follow their norms of deposit/running bills etc. However, provider



shall only charge the balance amount over and above the amount authorized under

the health insurance policy against the package or treatment from the insured.

17. Once the insured is to be discharged, the provider shall make a final request for the

preauthorization for any residual amount along with the standard discharge

summary and the standard billing format. Once the provider receives final pre-

authorization for a specific amount, the insured shall be allowed to get discharged

by paying the difference between the pre-authorised amount and actual bill, if any.

Insurer, upon receipt of the complete bills and documents, shall make payments of

the guaranteed amount to the provider directly.

18. Due to any reason if the insured does not avail treatment at the Provider after the

preauthorization is released, the Provider shall cancel the Pre-authorisation and

intimate to TPA immediately.

19. All the payments in respect of pre-authorised amounts shall be made electronically

by the insurer to the Net work provider as early as possible but not later than a 30

days from the date of receipt of all claim documents.

20. Denial of authorization (DAL) for cashless is by no means denial of treatment by

the health facility. The provider shall deal with such case as per their normal rules

and regulations.

21. Insurer shall not be liable for payments to the providers in case the information

provided in the “request for authorization letter” and subsequent documents during

the course of authorization, is found incorrect or not disclosed.

22. Provider, Insurer and its representative TPA shall ensure that the procedure

specified in this Schedule is strictly complied in all respects.

4.B Preauthorization Procedure - Emergency Admissions:

1. Request for hospitalization shall be forwarded by the provider immediately after

obtaining due details from the treating doctor /beneficiary in the pre-authorization

form prescribed i.e. “request for authorization letter” (RAL) as per Annex-I (this

form may change from time to time which will be informed, accordingly). The

RAL shall be sent along with all the relevant details in the electronic form to the

24-hour authorization /cashless department of the insurer or its representative TPA

along with contact details of treating physician and the insured. The insurer’s or its

representative TPA’s medical team may consult the treating physician or the

insured, if necessary.

2. The insurer or its representative TPA may continue to discuss with treating doctor

till conclusion of eligibility of coverage is arrived at. However, any life saving,

limb saving, sight saving, emergency medical attention cannot be withheld or



delayed for the purpose of waiting for pre-authorisation.

4.C Preauthorization Procedure - RTA / MLCs: 1. If requesting a pre-authorisation for any potential medico-legal case including

Road Traffic Accidents, the Provider shall indicate the same in the relevant section

of the standard form.

2. In case of a road traffic accident and or a medico legal case, if the victim was under

the influence of alcohol or inebriating drugs or any other addictive substance or

does intentional self injury, it is for the Provider to inform this circumstance of

emergency to the insurer or its representative TPA. 4.D Authorization letter (AL):

1. Authorization letter shall mention the amount, guaranteed class of admission,

eligibility, of the patient or various sub limits for rooms and board, surgical fees etc.

wherever applicable, as per the benefit plan for the patient.

2. The Authorization letter will also mention validity of dates for admission and

number of days allowed for hospitalization, if any. The Provider shall see that these

rules are strictly followed; else the AL will be considered null and void.

3. In the event the room category, if any, is not available the same shall be informed to

the insurer or its representative TPA and the insured. For such cases, if the insured

is admitted to a class of accommodation higher than what he is eligible for, the

provider shall collect the necessary difference, if any, in charges from the insured.

4. The AL has a limited period of validity - which is 15 days from the date of sending

the authorization.

5. AL is not an unconditional guarantee of payment. It is conditional on facts

presented – when the facts change the guarantee changes. 4.E Reauthorization:

1. Where there is a change in the line of treatment - a fresh authorization shall be

obtained from the insurer immediately - this is called a reauthorization.

2. The same pre-authorisation form shall be used for the reauthorization, and the same

turnaround times as specified shall apply.

4.F Discharge Procedure:

1. The following documents shall be included in the list of documents to be sent along

with the claim form to the insurer or its representative TPA. These shall not be

given to the insured:

a) Original pre authorization request form,



b) Authorization letter,

c) Original Discharge Card & Final Hospital Bill

d) All original investigation reports, prescription & pharmacy receipt etc

2. Where the insured requires the discharge card/reports he or she can be asked to take

photocopies of the same at his or her own expenses and these have to be clearly

stamped as “Duplicate, originals are submitted to insurer”.

3. The discharge card/Summary shall mention the duration of ailment and duration of

other disorders like hypertension or diabetes and operative notes in case of

surgeries. The clinical detail shall be sufficiently and justifiably informative.

4. Signature of the insured on final Provider bill shall be obtained.

5. In the event of death or incapacitation of the insured, the signature of the nominee

or any of insured’s of the family who represents the insured as such subject to

reasonable satisfaction of Provider shall be sufficient for the insurer to consider the

claim.

6. Standard Claim form duly filled in shall be presented to the insured for signing and

identity of the insured shall be confirmed by the provider.

Network Provider agrees to comply with the present & future requirements of insurers like

standardized pre-authorization form/discharge summary/billing, ICD-10 coding etc. In case

Network Provider doesn’t have such facility at their end, they agree to get such services

outsourced to a competent agency at their own cost. The following formats have been provided

with the MOU to be followed in this respect:

1. “Request for authorization letter” (RAL) as per Annex-I

2. Standard Format for Hospital Bill ----- Annex-II

3. Indicative list of inadmissible items provided as per Annex-III

4. Standard Format with guidelines for Discharge Summary ---- Annex-IV

4.G Billing Procedure:

1. The Provider shall submit original invoices directly to insurer or its representative TPA and such invoices shall contain, at the minimum, following information: a. the insured's full name and date of birth; b. the policy number; c. the insured's address; d. the admitting consultant; e. the date of admission and discharge; f. the procedure performed and procedure code according to ICD-10 PCS or any other code as specified by the Authority from time to time; g. the diagnosis at the time of treatment and diagnosis code according to ICD-10 or any other code as specified by the Authority from time to time; h. whether this is an interim or final bill/account;



i. the description of each Service performed, together with associated Charges, j. the agreed standard billing codes associated with each Service performed and dates on which items of Service were provide; and. k. the insured's signature (in original). 2. The Provider shall submit the following documents with the final invoice:

Original pre-authorization form; and signed copy of authorization letter issued by insurer or

TPA a. fully completed claim form or the relevant claim section of the pre-authorisation letter, signed by the insured and the treating consultant for the treatment performed; b. original and complete discharge summary in standard form and billing form in the standard form, including the treating Consultant's operative notes; c. original investigation reports with corresponding prescription/request;

d. pharmacy bill with corresponding prescription/request: e. any other relevant and/or statutory documentary evidence required under law or by the

insured's policy; and f. photocopy of the insured's photo identification (e.g. voter's Smart card/ ID card, passport or driving licence etc). g. Evidence of use of Implants/Lens, like bar coded stickers in original. h. Invoice in support of Implant cost 3. The Provider shall submit the final invoice and all supporting documentation required within 7 days of the discharge date Service network provider may endeavor to provide all claim records electronically including indoor case record.

4.I.: Limitations of Liability and Indemnity.

i. TPA/ Insurer will not interfere with the treatment and medical care provided to the

patients. TPA/ Insurer will not be in any way held responsible for the outcome of treatment or quality of care provided by the Provider.

ii. TPA/ Insurer shall not be liable or responsible for any acts of omission or commission

of the Doctors and other medical staff of the Provider.

iii. The Provider shall alone be liable to pay any costs, damages and/or compensation

demanded by the patients for poor, wrong or bad quality of the test report or treatment given to the patient by the Provider.

iv. Billing disputes will be resolved amicably between the Provider and the Insurer.

4.H: General Provisions:

1. The Provider shall subject to the availability of the beds extend priority admission

facility to the beneficiaries.

2. The Provider hereby ensures that it has cover of adequate insurance policy against any

error or omission in treatment as also negligence by its doctors and Para-medical staff and shall keep such policies in force during the subsistence of this agreement.



3. The Provider shall endeavor to have an officer of the Provider assigned for the patients

and shall endeavor to ensure that such officer learns various types of medical benefit offered by different insurance plans.

4. The Provider shall allow the qualified medical representatives of TPA/ INSURER to visit the patients and generally discuss the medical treatment to be given by the Provider to the patients provided always the final decision with respect to the line of treatment to be given to the patients shall be that of the Provider and its team of doctors, and the representatives of TPA/INSURER shall not interfere with the same, However they have the right to know the treatment plan and discuss the same with the provider.

5. If found necessary by TPA/INSURER to depute an authorized representative, the Provider shall allow with prior appointment or otherwise, the authorized representatives to have an access to the standardized billing and medical records, Electronic Medical Records, Indoor Case Papers, (Without any charge ) International Coding of Diseases after the patient is discharged or during the period of the hospitalization. Provider will not charge any additional cost

6. The Provider shall comply with the statutory requirements and follow the law of the land.

7. Network Provider agrees to have medical audit/bills audit, periodically, and as and when necessary through an authorized person(s) appointed by TPA/Insurer. Free access will be provided to all systems and data related to medical bill under audit, whether physical or electronic, whenever asked by such representative

8. The Provider will convey to the Doctor treating the patient to keep the patient only for

the required number of days of treatment and carry out only the required investigation and treatment for the ailment for which he/she is admitted and the decision in this regard of the attached Doctor shall be final and binding on the parties. In the event of any complications and/or emergency the treatment for the same will be included and permitted as necessary treatment and the attached Doctor shall at all times have the rights to treat the patient as he/she considers in his/her absolute discretion fit and necessary. Any other investigations required by the patient for his/her benefit are not reimbursable and hence not payable by TPA/INSURER and the Doctor will inform the patient that he/she will have to bear the costs of the same. However if there is any deviation in the line of treatment or from the information given in the Pre - Authorization request TPA/INSURER shall not be considered liable and the patient will have to bear the cost for the same and the provider would be required to recover the same from the patient.

9. The agreement is subject to the agreed package charges from time to time and for rest of the diseases/procedures, the detailed schedule of charges to be submitted by the Provider, which has to be agreed by Insurer/TPA.

10. Provider agrees to deal with Insurer/TPA and will guarantee the confidentiality of the Insurer/TPA data.

11. AL is issued on behalf of the first party (As per format attached) and after approval of



the first party and all payment rights/liabilities/obligations would be to the account of the first party .

12. In case the provider has any issues, the same needs to be clarified urgently with t h e I n s u r e r / T P , a s t h e c a s e m a y b e . Any harassment or denial of service to the insured/ beneficiary without prior notice to the TPA/Insurer shall be construed as violation of this Agreement.

13. T h e T P A / I n s u r e r shall conduct surprise checks of the provider to ensure display of posters and also check the knowledge of the provider’s staff about the cashless process and recognition of ID cards, and generally the quality and nature of services provided by the provider. Any deficiencies as observed during the course of any such inspection shall also be regarded as violation of the agreement.

This agreement super cedes all earlier agreements signed by the TPA,s individually with the

provider

Clause 5: TARIFF SCHEDULE.

1. The Provider will submit their Tariff schedule for the approval of insurer. The Provider

if already on the network will continue as per the rates accepted on date and will have to inform TPA/INSURER in case of any changes. Fee schedules may be adjusted every 24 months but not greater than general inflation as per RBI Indices. New services or new procedures must be discussed and rates agreed upon prior to providing services.

2. Any revision in the schedule of tariff has to be by mutual consent only, otherwise the

payment will be effected as per the agreed schedule of tariff in the MOU.

3. Any revision in schedule of tariff is effective only from the date of approval of the

revised schedule of tariff by TPA/INSURER in writing.

4. Tax Deduction at source (TDS):- Income tax would be deducted by the first party

(Insurer) U/s 194J at applicable rate as per Income Tax Act, 1961 from the Bill amount and deposited with Govt. At the year end and TDS Certificate will be issued for such deduction of TDS amount.

5. Other than agreed packages the Net Work Providers would provide a discount from the Standard Charges (SOC,s ) in line with the Package rate.

6. Provider agrees with the below mentioned clauses pertaining to Package Charges -

6.1 Provider should charge as per the attached package charges (which is subject to

change only with mutual understanding in writing). Such package charges must be

inclusive of stay, medicines, investigations, consumables, surgical fees, operation

theatre etc. No additional payment would be entertained unless the medical team of

TPA agrees with treating consultant for any deviation and the Provider explains the

insured patient that no amount will be admitted beyond the PPN package by the

TPA/Insurer and takes a written undertaking from the insured patient that no claim will

be lodged for this amount from the TPA/Insurer.



6.2 Provider agrees that if two procedures are done in a single hospitalization then full

package for Major/1st procedure and 50% of the Minor/2nd Procedure will be considered

for settlement. In case there is a third procedure that will be considered at 25% and so

on.

Clause 6 : PAYMENT TERMS AND CONDITIONS.

1. Insurer hereby agrees and undertakes to pay all the eligible bills within 30 working days

of the receipt of the complete claim docket along with the bill at Insurer/TPA office along with all the documents mentioned above.

2. In case certain billed items do not tally with the corresponding reports; the related bill

amount will be held back from payment of the final bill, which means Insurer shall make part payment of the total billed amount to the Provider for which Insurer is satisfied that the same is payable under the Bill. Due reason for such deductions, if any, will be given at the time of settlement of bills by Insurer to the Provider. Clarification by the Provider may be sent within 15 days of receiving the part payment as afore stated to receive the remaining payment if the Provider wishes to collect the balance amount.

3. Payment will be done directly by the Insurer to the Provider by NEFT /Electronically

4. If Provider fails to fulfill the deficiency raised by TPA within a period of 7 working

days from the date on which such deficiency is raised, a. In case where the deficiency does not pertain to the admissibility of the claim, the

claim shall be short paid mentioning the reasons. b. In case where the deficiency pertains to the admissibility of the claim, the claim shall

be closed mentioning the reasons.

5. In case the claim file along with the relevant & complete set of documents is not

forwarded to TPA within the prescribed period stipulated, TPA and Insurer will not be liable for making payment against such claims for delayed submission of claims files.

6. The Provider shall submit its queries regarding payment to TPA within 15 working

days from the date of payment or the date of closure as the case may be.

7. Acceptance and encashment by the Provider would be construed as due receipt if a

Provider omits to send a stamped receipt for the payment received.

8. The power to deny a claim lies solely & only with the Insurer.

Clause 7 : CONFIDENTIALITY.

The parties here to undertake to protect the secrecy of all the data of / the patient and trade

or business secrets of the Provider and Insurer and shall not share the same with any

unauthorized person for any reason whatsoever with or without any consideration. Provided

always in case of any legal action which may filed by a patient and/or his/her relatives

against the Provider or its doctors it will be open for the Provider to submit all the



documents to the concerned Court/Tribunal.

Provider specifically agrees to deal directly with Insurer/TPA and will not share the data

with any 3rd party Clause 8 : TERMINATION.

1. TPA and Insurer or the Provider shall reserve the right to terminate the agreement by

giving 30 days prior notice in writing.

2. However, in case of gross breach of terms and conditions of this MOU by the provider,

TPA and/or Insurer shall reserve the right to terminate the MOU with immediate effect.

Gross breach would include inter alia acts such as: a. Failure to perform any material obligation under this Agreement, by the

Provider. b. The failure to maintain any license, certification or accreditation required to

conduct business or perform under this Agreement

c. if Provider is declared bankrupt or insolvent, approves a petition seeking reorganization of the party or appoints a receiver, trustee, or liquidator for all or a substantial part of the party’s assets

d. if there is a change in the controlling interest of either party which affects its

financial ability or performance under this Agreement.

e. If any claim is/are in any respect fraudulent, or if any fraudulent means or devices are used by the Provider or anyone acting on his behalf to obtain any benefit under this MOU, Before terminating or modifying this MOU the provider will be given appropriate and enough time and opportunity to explain its stand.

f. The above list is only illustrative and not exhaustive.

3. In the event this agreement is terminated and a Beneficiary remains under care at the

Provider on or after the effective date of such termination, Provider shall be obliged to continue the provision of Health Services to that Beneficiary as per the actual agreement, until he or she is discharged. The Provider agrees not to bill Beneficiary for services if authorized by TPA, and hold the Beneficiary Person only financially responsible for non-authorized expenses. Insurer shall render payment in accordance with the issued Authorization Letter and in the amounts established by this Agreement.

4. TPA will provide administrative services as described in this Agreement for any claims

that were incurred prior to the termination of this Agreement, so long as authorization and coverage under the benefit plan exist.

Clause 9: PROCEDURE FOR DE-EMPANELLEMENT OF NETWORK PROVIDER



Steps 1 - Putting the Provider on “Watch-list”

1. Based on the claims data analysis and/ or the Provider visits, if there is any doubt on the performance of a Provider, the Insurance Company can put that Provider on the watch list. 2. The data of such Provider shall be analyzed very closely on a daily basis by the Insurance Company for patterns, trends and anomalies. Step 2 - Suspension of the Provider 3. A Provider can be temporarily suspended in the following cases: a. For the Providers which are in the “Watch-list” if the Insurance Company observes continuous patterns or strong evidence of irregularity based on either claims data or field visit of Providers, the Provider shall be suspended from providing services to policyholders/insured patients and a formal investigation shall be instituted.

b. If a Provider is not in the “Watch-list”, but the insurance company observes at any stage that it has data/ evidence that suggests that the Provider is involved in any unethical practice/ is not adhering to the major clauses of the contract with the Insurance Company involved in financial fraud related to health insurance patients, it may immediately suspend the Provider from providing services to policyholders/insured patients and a formal investigation shall be instituted. 4. A formal letter shall be send to the Provider regarding its suspension with mentioning the Time frame within which the formal investigation will be completed. Step 3 - Detailed Investigation

5. The Insurance Company can launch a detailed investigation into the activities of a Provider in the following conditions: a. For the Providers which have been suspended.

b. Receipt of complaint of a serious nature from any of the stakeholders. 6. The detailed investigation may include field visits to the Providers, examination of case

papers, talking with the policyholders/insured (if needed), examination of Provider records etc.

7. If the investigation reveals that the report/ complaint/ allegation against the Provider is not

substantiated, the Insurance Company would immediately revoke the suspension (in case it is

suspended). A letter regarding revocation of suspension shall be sent to the Provider within 24

hours of that decision. Step 4 - Action by the Insurance Company

8. If the investigation reveals that the complaint/allegation against the Provider is correct then following procedure shall be followed: a. The Provider must be issued a “show-cause” notice seeking an explanation for the

aberration.



b. After receipt of the explanation and its examination, the charges may be dropped or an action can be taken.

Schedule-II c. The action could entail one of the following based on the seriousness of the issue and other factors involved: i. A warning to the concerned

Provider, ii. De-empanelment of the Provider.

9. The entire process should be completed within 30 days from the date of suspension. Step 5 - Actions to be taken after De-empanelment 10. Once a Provider has been de-empanelled by insurer, following steps shall be taken:

a. A letter shall be sent to the Provider regarding this decision. b. This information shall be sent to all the other Insurance Companies which are doing health insurance business. c. The Insurance Company which had de-empanelled the Provider may be advised to notify the same in the local media, informing all policyholders/insured about the de-empanelment, so that the beneficiaries do not utilize the services of that particular Provider. d. If the Provider appeals against the decision of the Insurance Company, the aforementioned actions shall be subject to the dispute resolution process agreed in the service level agreement.

Clause 10: Continuation of Services.

Even if the agreement between TPA and Insurer is terminated the provider shall continue providing services to the above mentioned Insurer. Clause 11: Non- Exclusivity

TPA and Insurer reserve the right to appoint other Providers and the Provider shall have no objection for the same. Clause 12: JURISDICTION.

12.1. i. The provisions of this Agreement shall be governed by, and construed in accordance with Indian law.

12.2. ii Any disputes, claims arising out of this Agreement are subject to Arbitration

and jurisdiction exclusively of ------------ Courts. Any dispute and differences arising between the parties shall be adjudicated and resolved by a Sole Arbitrator appointed by TPA and Insurer as per the provisions of the Arbitration and Conciliation Act, 1996 and amendments thereof

12.3. iii. The arbitral tribunal shall be composed of three arbitrators, one arbitrator

appointed by each Party and one another arbitrator appointed by the mutual consent of the arbitrators so appointed.

12.4. iv. The place of arbitration shall be and any award whether interim or final, shall be

made, and shall be deemed for all purposes between the parties to be made, in Indian Rupees.



12.5. v. The arbitral procedure shall be conducted in the English language and any award or awards shall be rendered in English. The procedural law of the arbitration shall be Indian law.

12.6. vi. The award of the arbitrator shall be final and conclusive and binding upon the

Parties, and the Parties shall be entitled (but not obliged) to enter judgment thereon in any one or more of the highest courts having jurisdiction.

12.7. vii. The rights and obligations of the Parties under, or pursuant to, this Clause

including the arbitration agreement in this Clause, shall be governed by and subject to Indian law.

12.8. viii. The cost of the arbitration proceeding would be born by the parties on equal

sharing basis.

12.9. Any amendments in the clauses of the Agreement can be effected as an

addendum, after the written approval from any party.

Clause 13: Commencement.

The Effective Date of this Agreement is the date of signature by the Parties (if signed by the parties on separate dates, the latter of the three) and shall remain in full force and effect for 12 full months after the Date of Signing and shall automatically renew for subsequent years term, unless terminated as provided for in Clause 8

Clause 14: General Conditions

14.1 Neither party shall be liable for any failure or delay in performance under this

Agreement to the extent said failures or delays are proximately due to causes beyond

that party's reasonable control and occurring without its fault or negligence, including,

but not limited to: natural disaster (earthquake, hurricane, flood); war, riot or other

major upheaval; performance failures of external parties to the Agreement (e.g.,

disruptions in telephone service attributable to the telephone company). As a condition

to the claim of non-liability, the party experiencing the difficulty shall give the

other prompt written notice of the occurrence. Dates by which

performance obligations are scheduled to be met will be extended as agreed between

the parties.

14.2 During the term of this Agreement the Provider authorizes TPA and INSURER to make

reference to the Provider and its affiliated providers as part of “TPA” Provider Network

to the Beneficiaries. Provider, provider affiliates, and “TPA” shall not otherwise use the

other Party’s name, symbol or service mark without prior written consent, which shall

not unreasonably be with held.

14.3 All notices from one party to the other party pursuant to this Agreement shall be in

writing and shall be delivered either personally, by nationally recognized overnight delivery service, courier services, or by certified or registered post.

14.4 The date of receipt and effective date of the notice will be determined as follows:

a) The date on the signed receipt if delivered personally, by overnight service, or

courier.



b) The date indicated on the return receipt if delivered by registered or certified mail.

14.5 It is agreed by and between the parties:-

a. The Article and other headings contained in this Agreement are for reference

purposes only and shall not affect the meaning or intention of this Agreement.

b. No amendment to this Agreement is valid unless it is reduced to writing and

duly signed by all the parties, unless the amendment is deemed to be automatic

as per the terms of this agreement.

c. In the event of any inconsistency between the provisions of this Agreement and

the Schedules/annexure hereto, the provisions of the Agreement shall prevail

over that of the Schedule. However, both the parties agree and understand that

the IRDA guidelines on Standardization of Health Insurance issued vide IRDA/

HLT/CIR/036/02/2013 dt. 20/02/2013 and the IRDA (Health Insurance)

Regulations, 2013, the parties shall be bound by the same. In case there is any

inconsistency or repugnancy between the provisions of the aforesaid IRDA

Guidelines and Regulations on the one hand and the provisions this Agreement

on the other, the parties shall be bound by the former for all their intents and

purposes. The parties hereto agree that the provisions of this agreement are in

addition to and not in derogation of any of the provisions of the aforesaid IRDA

Guidelines and Regulations, and that the same shall be deemed to have been

engrafted in this agreement.

d. If any or more provisions of this Agreement, or any part or parts thereof,

should, for any reason, be found to be illegal, unenforceable or of no effect in

any respect, the same shall be severed from this Agreement and the remaining

provisions shall be valid and binding and shall not in any way be affected or

impaired thereby.

e. The Insurer shall have discretion at all times, in modifying, adding, deleting or

cancelling the contents of this agreement, at its sole discretion, and that the other

parties shall be bound by the same.

f. Any express waiver of any term or condition in this Agreement or waiver of a

breach of such term or condition shall not constitute a waiver of any of the other



terms and conditions or of any future breach or breaches of any term or

condition or operate as a continuing waiver.

g. Neither party can assign its right and obligations under this Agreement to any

third party, without the prior written consent of the other two parties. However,

this shall not apply to any right or obligation that would befall any party to this

agreement on account of portability of insurance (subject to the Regulations of

IRDA) as opted by any insured in terms of the IRDA (Health Insurance)

Regulations, 2016 or any amendment modification thereto.

h. Neither party shall transfer its rights or obligations in any manner what so ever without the

prior consent of the other parties.

i. This agreement is entered into by the parties hereunto on principal to principal basis,

and as such neither party shall be deemed to be the agent of the others or partner of the

others.

Clause 15: List of TPA which are empanelled by the insurer to carry out health insurance related services as per IRDA regulation and who are duly licensed. As per Annexure V

1. SIGNED SEALED AND DELIVERED by the within named

_______________________

Insurance Company Ltd. by the hand of its duly Constituted Attorney

Through __________________________________

in the presence

of __________________________________

2. SIGNED SEALED AND DELIVERED by the

Within named Provider _____________________________________________ By the hand of its duly Constituted Attorney

Through __________________________________

in the presence of __________________________________

3. SIGNED SEALED AND DELIVERED by the



Indicative List of commonly excluded Items -------Annex-III

Sr

No

Items

Recommendations A. Toiletries/Cosmetics/Personal Comfort or

Convenience Items

A 1 Hair removing cream charges Not Payable

A 2 Baby Charges (unless specified/indicated) Not Payable

A 3 Baby food Not Payable

A 4 Baby utilities charges Not Payable

A 5 Baby set Not Payable

A 6 Baby Bottles Not Payable

A 7 Bottle Not Payable

A 8 Brush Not Payable

A 9 Cosy Towel Not Payable

A

10 Hand Wash Not Payable

A

11 Moisturiser Paste Brush Not Payable

A

12 Powder Not Payable

A

13 Razor Not Payable

A

14 Towel Not Payable

A

15 Shoe Cover Not Payable

A

16 Beauty Services Not Payable

A

17 Buds Not Payable

A

18 Barber charges Not Payable

A

19 Caps Not Payable

A

20 Cold pack/hot pack Not Payable

A

21 Carry bags Not Payable

A

22 Cradle charges Not Payable

A

23 Comb Not Payable

A

24 Disposable razor charges (for site preparations) Payable

A

25 Eau-De-Cologne/Room freshners Not Payable

A

26 Eye pad Not Payable

A Eye shield Not Payable



27

A

28 Email/Internet charges Not Payable

A

29

Food charges (other than Patient's Diet

Provided by Hospital) Not Payable

A

30 Foot cover Not Payable

A

31 Gown Not Payable

A

32 Laundry charges Not Payable

A

33 Mineral water Not Payable

A

34 Oil charges Not Payable

A

35 Sanitary pad Not Payable

A

36 Slippers Not Payable

A

37 Telephone charges Not Payable

A

38 Tissue paper Not Payable

A

39 Tooth paste Not Payable

A

40 Tooth Brush Not Payable

A

41 Guest services Not Payable

A

42 Bed pan Not Payable

A

43 Bed under pad charges Not Payable

A

44 Camera cover Not Payable

A

45 Care free Not Payable

A

46 Cliniplast Not Payable

A

47 Crepe bandage Not Payable

A

48 Curapore Not Payable

A

49 Diaper of any type Not Payable



A

50 DVD,CD charges

Not Payable(however if CD is specifically sought

by insurer/TPA then payable)

A

51 Eyelet Collar Not Payable

A

52 Face mask Not Payable

A

53 Flexi mask Not Payable

A

54 Gause soft Not Payable

A

55 Gauze Not Payable

A

56 Hand holder Not Payable

A

57 Hansaplast/Adhesive Bandages Not Payable

A

58 Lactogen/Infant food Not Payable

B. Items which form part of hospital services

where separate consumables are not payable

but the service is

B 1 Ward & theatre booking charges Payable under OT charges,Not Payable separately

B 2 Anthroscopy & Endoscopy instruments

Rental charged by the hospital payable.Purchase

of Instruments not payable

B 3 Microscope cover Payable under OT charges,Not Payable separately

B 4 Surgical blades,harmonic scalpel,shaver Payable under OT charges,Not Payable separately

B 5 Surgical drill Payable under OT charges,Not Payable separately

B 6 Eye kit Payable under OT charges,Not Payable separately

B 7 Eye drape Payable under OT charges,Not Payable separately

B 8 X- ray film

Payable under Radiology charges,not as

consumables

B 9 Sputum cup

Payable under Investigation charges,not as

consumables

B

10 Boyles apparatus charges Payable under OT charges,Not Payable separately

B

11

Blood grouping and cross matching of donors

samples Part of cost of blood,not payable

B

12 Savlon Not payable- part of dressing charges

B

13

Band aids,bandages,sterile

injections,needles.syringes Not payable -part of dressing charges

B

14 Cotton Not payable -part of dressing charges

B

15 Cotton bandages Not payable -part of dressing charges



B

16 Micropore/Surgical tape

Not payable- payable by the patient when

prescribed,otherwise included as dressing charges

B

17 Blade Not Payable

B

18 Apron

Not Payable-part of hospital services/disposable

linen to be part of OT/ICU charges

B

19

Torniquet

Not Payable(service is charged by

hospitals,consumables cannot be separetly

charged)

B

20 Orthobundle,Gynaec bundle Part of dressing charges

B

21 Urine container Not Payable

C. Elements of Room Charge

C 1 HVAC Not payable- part of room charges

C 2 House keeping charges Not payable- part of room charges

C 3

Service charges where nursing charge also

charged Not payable- part of room charges

C 4 Television & Air conditioner charges Not payable- part of room charges

C 5 Surcharges Not payable- part of room charges

C 6 Attendant charges Not payable- part of room charges

C 7 IM/IV injection charges Part of nusing charges ,not payabe

C 8 Clean sheet

Part of laundry/house keeping charges,not payable

separately

C 9

Extra diet of patient(other than that which

forms part of bed charges) Patient diet provided by hospital is payable

C

10 Blanket/warmer blanket Not payable- part of room charges

D. Administrative or Non medical charges

D 1 Admission Kit Not payable

D 2 Birth certificate Not payable

D 3

Blood reservation charges & ante natal booking

charges Not payable

D 4 Certificate charges Not payable

D 5 Courier charges Not payable

D 6 Conveyance charges Not payable

D 7 Diabetic chart charges Not payable

D 8

Documentation charges/Administrative

Expenses Not payable

D 9 Discharge procedure charges Not payable

D

10 Daily chart charges Not payable

D Entrance pass/Visitors pass charges Not payable



11

D

12 Expenses related to prescription on discharge

To be claimed by patient under post

Hospitalisation where admissible

D

13 File opening charges Not payable

D

14

Incidental expenses/Misc.charges (Not

explained) Not payable

D

15 Medical certificate Not payable

D

16 Maintainance charges Not payable

D

17 Medical records Not payable

D

18 Preparation charges Not payable

D

19 Photocopies charges Not payable

D

20 Patient indentification band/Name tag Not payable

D

21 Washing charges Not payable

D

22 Medicine box Not payable

D

23 Mortuary charges Payable upto 24 hrs.shifting charges not payable

D

24 Medico legal case charges(MLC charges) Not payable

E. External Durable Devices

E 1 Walking Aids charges Not payable

E 2 Bipap Machine Not payable

E 3 Commode Not payable

E 4 CPAP/CPAD equipments Device not payable

E 5 Infusion pump-cost Device not payable

E 6

Oxygen cylinder (for usage outside the

hospital) Not payable

E 7 Pulseoxymeter Charges Device not payable

E 8 Spacer Not payable

E 9 Spirometre Device not payable

E

10 SPo2 probe Not payable

E

11 Nebulizer kit Not payable

E

12 Steam inhaler Not payable



E

13 Armsling Not payable

E

14 Thermometer Not payable

E

15 Cervical collar Not payable

E

16 Splint Not payable

E

17 Diabetic foot ware Not payable

E

18 Knee braces(long/short/hinged) Not payable

E

19 Knee immobilizer/shoulder immobilizer Not payable

E

20

Nimbus bed or water or air bed charges

Payable for any ICU .Patient requiring more than

3 days in ICU,all patients with

Paraplegia,quadriplegia for any reason and at

reasonable cost of approximately Rs 200/day

E

21 Ambulance collar Not payable

E

22 Ambulance equipment Not payable

E

23 Microsheild Not payable

F.Items Payable if supported by a

prescription

F 1

Betadine/hydrogen

peroxide/spirit/dettol/savlon/disinfectants etc.

May be payable when prescribed for patient,not

payable for hospital usage in OT or ward or for

dressings in hospital

F 2 Private nurses charges-Special nursing charges Post hospitalisation nursing charges not payable

F 3

Nutrition planning charges-Dietician charges-

Diet charges

Not payable separately, patient diet part of room

charge

F 4

Cream powder lotion(toileteries are not

payable,only prescribed medical

pharmaceuticals payable)

Payable when prescribed

F 5

ECG electrodes

Upto 5 electrodes are required for every case

visiting OT or ICU.For longer stay in ICU, May

require a change and at least one set every second

day must be payable.

F 6 Gloves

Sterilized gloves payable/unsterilized gloves not

payable

F 7 HIV kit Payable-pre operative screening

F 8 Nebulisation kit

If used during hospitalisation is payable

reasonably

F 9 Vaccination charges Routine Vaccination not payable/post bite



vaccination payable

G.Part of Hospital's own cost & not payable

G 1 AHD Not payable-Part of Hospital's internal cost

G 2 Alcohol swabs Not payable-Part of Hospital's internal cost

G 3 Scrub solution/sterillium Not payable-Part of Hospital's internal cost

H Others

H 1 Vaccine charges for Baby Not Payable

H 2 Aesthetic treatment/Surgery Not Payable

H 3 TPA charges Not Payable

H 4 Visco belt charges Not Payable

H 5

Any kit with no details mentioned (delivery

kit,orthokit,Recovery kit,etc.) Not Payable

H 6 Examination gloves Not Payable

H 7 Kidney tray Not Payable

H 8 Mask Not Payable

H 9 Ounce glass Not Payable

H

10 Outstation consultant's/Surgeon's fees

Not Payable,except for telemedicine consultations

where covered by policy

H

11 Oxygen mask Not Payable

H

12 Paper gloves Not Payable

H

13 Referal Doctor's fee Not Payable

H

14

Accu Check (Glucometery/Strips)

Not payable pre hospitalisation or post

hospitalisation/reports and charts required/Device

not payable

H

15 Pan can Not payable

H

16 Softnet Not payable

H

17 Trolly cover Not payable

H

18 Urometer,Urine jug Not payable

H

19

Ambulance

Payable-Ambulance from home to hospital or

interhospital shifts is payable/RTA as specific

requirement is payable

H

20 Tegaderm/Vasofix safety

Payable- Maximum of 3 in 48 hrs. and then 1 in

24 hrs.

H

21 Urine bag

Payable where medicaly necessary till a

reasonable cost.Maximum 1 per 24 hrs

H Softovac Not payable



Within named Provider as per Annexure-V (Enclosed Annexure I to V)

STANDARD FORMAT FOR PROVIDER BILLS

1. Components of standardization: Standardization involves three components: i. Bill Format ii. Codes for billing items and nomenclature iii. Standard guidelines for preparing the bills. 2. Format Specified: The bill is expected to be in two formats.

i. The summary bill ( ANNEXURE II) Schedule-IV A and ii. The detailed breakup of the bills. ( ANNEXURE II_A Schedule-IV B ) 3. Explanation and Guidelines - Summary Bill

i. The summary form

ii. The Bill shall be generated on the letter head of the provider and in A4 size to aid scanning.

iii. The summary bill shall not have any additional items (only 9) iv. The provider has to mention the service tax number in case they charge service tax to the insurance company. v. The payer mentioned in the bill has to be necessarily the insurance company and not the

TPA. vi. In case of package charged for any procedure/treatment, the provider is expected to mention the amount in serial no 9 only. Items beyond the package are to be mentioned in serial numbers 1 to 8. vii. The patient/attendant signature is mandatory on the summary bill

viii. The additional guidelines to fill the summary format is provided in ( ANNEXURE II_B )

Annex-IV ---Standard Discharge Summary & Provider Bills :

The provider should make sufficient arrangements so as to conform to the format & guidelines

herein to the standard Discharge Summary & Provider Bills for speedy settlement of bills.

4.8 STANDARD DISCHARGE SUMMARY 1. Components of standardization: a. List of standard contents in the discharge summary b. Standard guidelines for preparing a discharge summary so that the interpretation of the terms in the document and the information provided is uniform.

22



2. Standard Contents of Discharge Summary Format: a. Patient’s Name*:

b. Telephone No / Mobile No*: c. IPDNo:

d. Admission No: e. Treating Consultant/s Name, contact numbers and Department/Specialty :

f. Date of Admission with Time:

g. Date of Discharge with Time: h. MLC No/FIR No*:

i. Provisional Diagnosis at the time of Admission: j. Final Diagnosis at the time of Discharge:

k. ICD-10 code(s) or any other codes, as recommended by the Authority, for Final diagnosis*:

1. Presenting Complaints with Duration and Reason for Admission: m. Summary of Presenting Illness:

n. Key findings, on physical examination at the time of admission: o. History of alcoholism, tobacco or substance abuse, if any: p. Significant Past Medical and Surgical History, if any*: q. Family History if significant/relevant to diagnosis or treatment: r. Summary of key investigations during Hospitalization*:

s. Course in the Hospital including complications if any*: t. Advice on Discharge*: u. Name & Signature of treating Consultant/ Authorized Team Doctor: v. Name & Signature of Patient / Attendant*:

GUIDE NOTES FOR FILLING DISCHARGE SUMMARY FORMAT:

a. The patient’s name shall be the official name as appearing in the insurance policy document and the attendants should be made aware that it cannot be changed subsequently, because in some cases the attendants give the nick names which are different from documented names. As a matter of abundant precaution, all personal information should be shown to the patient/attendant and validated with their signatures. b. The contact numbers shall be specifically those of the patient and if pertaining to attendant, the same should be mentioned. c. Where applicable, copy of MLC/FIR needs to be attached d. Desirable not mandatory e. Significant past medical and surgical history shall be relevant to present ailment and shall provide the summary of treatment previously taken, reports of relevant tests conducted during that period. In case history is not given by patient, it should be specified as to who provided the same. f. Summary of key investigations shall appear chronologically consolidated for each type of investigation. If an investigation does not seem to be a logical requirement for the main disease/line of treatment, the admitting consultant should justify the reason for carrying out such test/investigation. g. The course in the hospital shall specify the line of treatment, medications administered,

operative procedure carried out and if any complications arise during course in the hospital, the

same should be specified. If opinion from another doctor from outside hospital is obtained,



reason for same should be mentioned and also who decided to take opinion i.e. weather the

admitting and treating consultant wanted the opinion as additional expertise or the patient

relatives wanted the opinion for their reassurance. h. Discharge medication, precautions, diet regime, follow up consultation etc should be specified. If patient suffers from any allergy, the same shall be mentioned.

The signatures/Thumb impression in the Discharge Summary shall be that of the patient because generally the patient is discharged after having improved. In other cases like Death summary or transfer notes in case of terminal illness, the attendant can sign, the inability of the patient to sign should be recorded by the attending doctor.

memorandum of understanding (mou) - alankit healthcare · memorandum of understanding (mou) ......

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