MEMORANDUM OF UNDERSTANDING RAJIV AAROGYASRI - II

AS –II (2nd Renewal)This Agreement is made at Hyderabad on this ____ th day of _____________ 2010 between AAROGYASRI HEALTH CARE TRUST., a Trust incorporated under the Indian Trusts Act and having its Office at Dr YSR Bhavan, Road No 46, Jubilee Hills, Hyderabad 500 033 hereinafter referred to as "TRUST” which expression shall unless it be repugnant to the context or meaning thereof shall deem to mean and include its successors and assigns of the ONE PART.AND_______________________________________________________ rep by CEO/Managing Director/Proprietor/Superintendant and having its Registered Office at ____________________________________________________ _____________________________________________________________ hereinafter referred to as PROVIDER which expression shall unless it be repugnant to the context or meaning thereof be deemed to mean and include its successors and assignees of the OTHER PART.WHEREAS, Trust is an independent nodal agency setup by the Govt of AP, providing Health care coverage to BPL families in state through self funded scheme Aarogyasri-II (2nd Renewal) in 15 ( East Godavari, West Godavari, Ranga Reddy, Chittoor, Nalgonda, Vishakapathanam ,Vizianagaram, Hydearbad, Kurnool, Adilabad, Guntur, Krishna, Karimnagar, Warangal and Nizamabad ) districts for specified surgeries / Therapies as given in the booklet ‘“Rajiv Aarogyasri Manual on Surgical &

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Medical Treatments for Cashless Treatment of BPL Population - 3rd edition” of Aarogyasri Health Care Trust (published by Trust) for which purpose Trust has created a network of service Providers. ______________________________________________ desires to join the said network of Providers and is willing to extend cashless medical facilities for the surgical /Therapeutic procedures as per “Rajiv Aarogyasri Manual on Surgical & Medical Treatments for Cashless Treatment of BPL Population - 3rd edition” of Aarogyasri Health Care Trust to the members of Below Poverty Line (BPL) families identified either by Rajiv Aarogyasri Health Card or BPL Ration Card and referred to them by the Trust under the Aarogyasri-II Scheme of the Government of Andhra Pradesh.

Now this Agreement witnesseth as under:Art. 1: Definitions:

1.1 ‘Trust’: Aarogyasri Health Care Trust. 1.2 ‘IRDA’: Insurance Regulatory and Development Authority. 1.3 ‘Hospital’: Hospital Registered under A.P Allopathic Private Medical Establishment Act with minimum 50 beds.1.4 ‘Network Hospital/NWH’: Hospital empanelled under Aarogyasri Health care Scheme.1.5. ‘MOU’: Memorandum of Understanding between the Insurance & Empanelled Hospital.1.6 ‘Surgery/Surgeries’: means cutting, abrading, suturing, laser or otherwise physically changing body tissues and organs by qualified medical doctor who is authorized to do so. 1.7 ‘Therapy/Therapies’: Standard way of medical treatment to the patient as per the medical protocols of Allopathic medicine.1.8 ‘Treatment’: Medical management by qualified Doctor in the Network hospital.1.9 ’Aarogyamithra’: First contact person for Aarogyasri patient at Network Hospital. 1.10 ‘RAMCO’ Rajiv Aarogyasri Medical Coordinator – Medical Coordinator from the Network Hospital with minimum MBBS qualification to coordinate with Trust/Insurer.1.11. ‘AMCCO’: an Officer designated as Aarogyasri Medical Camp Coordinator for the scheme to coordinate with Trust/Insurer through Aarogyamithra.1.12. ‘IEC’: Information, Education & Communication.1.12. ‘TAT’: Turn Around Time. 1.13. ‘Pre-Authorization’: Pre-Authorization is a process by which an Insured Person obtains written approval for certain medical procedures or treatments, from Trust/Insurance.1.14. ‘EDC’: Empanelment & Disciplinary Committee.

Article 1a: Effective Date:

1a. This agreement will be in force for a period of one year commencing from 17-07-2010 to 16-07-2011 or until otherwise terminated as provided for in this MOU and shall be extended by mutual consent under same terms and conditions.

Article 2: General Provisions:

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2.1 General UndertakingProvider warrants that it has all the required facilities for performing the enlisted surgeries / procedures / therapies as specified in clause. No 3.

2.2 Minimum Bed Strength and Specialty Wise Bed Capacity Provider declares that the hospital has the required number of bed capacity (50) under the scheme and will declare the specialty wise allocation of beds in the proforma submitted below and uploaded in Trust portal.

Total Bed Strength

Code Specialty Total No of Beds

S1 General Surgery

S2 ENT

S3 Ophthalmology

S4 Gynecology &Obstetrics

S5 Orthopedics

S6 Surgical Gastroenterology

S7 Cardio Thoracic surgery

S8 Pediatric Surgery

S9 Genito Urinary surgery

S10 Neuro surgery

S11 Surgical Oncology

S12 Medical oncology

S13 Radio Oncology

S14 Plastic Surgery

S15 Polytrauma

M1 Critical care

M2 General Medicine

M3 Infectious Diseases

M4.1 Pediatric Intensive Care

M4.2 Neonatal Intensive care

M4.3 Pediatric General

M5 Cardiology

M6 Nephrology

M7 Neurology

M8 Pulmonology

M9 Dermatology

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M10 Rheumatology

M11 Endocrinology

M12 Gastroenterology

2.3 Allocating minimum 25% of beds in network hospitals for Aarogyasri patients:Provider agrees to provide at least 25% of their bed capacity available for occupation by Aarogyasri patients for treatment under each specialty available in the hospital and under which the procedures are covered in the Rajiv Aarogyasri Scheme. 2.4 Conduct of OP services:2.4a Provider agrees provide separate OP facilities for Aarogyasri patients, to be manned by “Medical Coordinator” of the hospital (RAMCO) and Aarogyamithra(s).2.4b Provider agrees to do general counseling for all OP patients to ascertain their eligibility under Aarogyasri to avoid later conversion of cash patients at a later date.2.5 Conversion of cash patients into Aarogyasri:Provider agrees to take a declaration from patient at the time of admission itself on the applicability or otherwise of Aarogyasri in his/her case. In emergency /trauma cases, patients may be allowed 48 hours after admission to claim Aarogyasri benefit. 2.6 Online Updation of Bed Occupancy:Provider agrees to upload the bed occupancy under each specialty for which hospital is empanelled as and when required.2.7 Point of Contact:The first point of contact for all the patients (out patients and in patients) coming under the Scheme will be the Aarogyamithra positioned at Network Hospital 2.8. Guidelines:The Provider agrees to follow ALL the guidelines in rendering the services to Aarogyasri patient annexed hereto as part & parcel of this MOU. The Provider also agrees to follow and adhere to the guidelines issued by the Trust / Insurer from time to time.2.9 ON-LINE Workflow:The Provider agrees to follow & adhere to the ON-LINE workflow of the Aarogyasri community Insurance Scheme in providing services to Aarogyasri patients.2.10 Eligibility Criteria:

The provider agrees to follow the guidelines on eligibility criteria for admission of patients under Rajiv Aarogyasri Community Health Scheme as mentioned here under and the Following guidelines are re-emphasized by the Trust to be followed by Network hospitals in cases where clarifications are sought:S.NO

ANOMALY IN CARDS NATURE OF TREATMENT

REQUIREMENT FOR BENEFIT

1 No Rajiv Aarogyasri Health Card

- BPL Card.

2 No name but photo available in the white card/health card and photograph matches the patient

- Patient self declaration is enough.

3 Name is there but photo is not available on white card/Health card.

- Any Photo ID card (Driving License, College/School ID Certificate from Tahsiladar along with photograph etc..,) to correlate the patient

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name and photograph.4 Children born after issue of

card i.e. name and photo not available on card.

a. Neonatal and Pediatric emergencyb. Elective

a. Photograph of child with either parent along with Health card/BPL card of either parent and Birth certificate issued by the hospital or other authorized entities. b. Certificate issued by collector.

Article 3: Specialty/Specialties Empanelled for:3.1 Provider hereby declares that the hospital has requisite infrastructure as per Aarogyasri guidelines in relation to specialty services for which empanelment is done and agrees to provide quality diagnostic and treatment services as per the standard protocols. 3.2 Provider hereby declares that hospital did not exclude any other specialty service deliberately from the scheme inspite of having such facility and agrees to empanel for all the specialties for which adequate infrastructure is available.3.3 The Hospital hereby declares that the bed capacity of the hospital is more than 50 with adequate infrastructure and manpower as per standard guidelines and agrees to provide separate male and female wards with toilet and other basic amenities.3.4 The Hospital declares that it has a well-equipped ICU to meet the emergency requirements of the patients belonging to all the categories empanelled for and agrees to facilitate round clock diagnostic and specialist services as per the requirement mentioned in clause 4. 3.5 Specialties: Provider agrees not to refuse admission of Aarogyasri patient in any specialty where it has consultants and equipment. A minimum of 25% of overall bed capacity and of beds in each specialty have to be made available to Aarogyasri patients in network hospital.3.6 Provider agrees to follow the guidelines issued by the Trust/Insurer on specific specialties annexed herewith (Refer Annexure V, XXVII).

Article 4: Empanelment: 4.1 Infrastructure and Manpower (General):

Well equipped theatre Casualty / 24 hrs duty doctor/Appropriate nursing staff Availability of trained paramedics Post-op ward with ventilator and other required facilities ICU with concerned specialty Round the clock lab and imagelogy support Availability of specialists in support fields. Facilities for Interventional Radiology and availability of concerned specialist.

4.2 Infrastructure and Manpower (Specific): Provider agree to provide the services of fully qualified Medical Oncologist, Radiation Oncologist and Surgical Oncologist – all or either and equipment for Cobalt therapy, Linear accelerator and Brachy therapy – all or either to be empanelled for Cancer Surgeries and Chemo and Radio-Therapies.

Note: A combination of both professional and the equipment is essential.

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Chemotherapy and Radiotherapy should be administered only by professionals well versed in dealing with the side-effects that the treatment can cause. Patients with Hematologic malignancies (Ex. Leukemia, Lymphomas and Multiple Myeloma) and Pediatric malignancies (Any patient < 14 years of age) should be treated by qualified medical oncologist only. Chemotherapy has to be administered to the patient as in-patient treatment only. Provider agrees to provide the services as per the packages and adhere to the treatment protocols (Refer Annexure –IV). The Service Provider will agree to quote batch no. of the drugs and attach empty vials and ampoules with labels intact along with the bills. The Provider will agree to give patients feedback through Multimedia having webcam and mike. The provision for live viewing of the patient will be provided in the Trust portal.

4.3 For Empanelment of Cochlear Implant Surgery with Auditory–Verbal Therapy: Provider agrees to provide the Services of Qualified and Trained ENT Specialist in Cochlear Implant Surgery and Auditory –Verbal Therapist. ( Refer Annexure-VIII & XII)

4.4 For Empanelment of Poly Trauma: The Provider will have Emergency Room Setup with round the clock dedicated duty doctor. Provider will have round the clock anesthetist services. Provider will be able to provide round the clock services of Neuro-surgeon, Orthopedic Surgeon, CT Surgeon and General Surgeon, Vascular Surgeon and other support specialties. Provider will have dedicated round the clock Emergency theatre, Surgical ICU, Post-Op Setup with qualified staff. Provider will be able to provide necessary cashless diagnostic support round the clock including specialized investigations such as CT, MRI, emergency biochemical investigations. Provider should put all necessary infrastructure required for preauthorization round the clock. ( Refer Annexure-VII)

4.5 For Empanelment of Pediatric Congenital Malformations and Post-Burns Contractures:

Provider will have services of qualified specialists in the field Viz., Pediatric Surgeon, Plastic Surgeon with dedicated theatres, post-op setup and staff.

4.6 For Empanelment of Prostheses (Artificial limbs): The hospital shall have full time services of Orthopedic Surgeon to be empanelled to provide prostheses package under the scheme. Hospital shall facilitate supply, fitting of appropriate prosthesis and gait training of patient by physiotherapist. Hospital shall ensure that an appropriate prosthesis is prescribed based on occupation of the person and standard prosthesis is supplied as per quality norms of BIS (Bureau of Indian Standards). Hospital shall also facilitate free replacement of leather parts and ensure total replacement of Prosthesis in case of damage during guarantee period of 3 years.

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4.7 The Network hospital which is in Delisted/suspended/stop payment status would forfeit right to re-empanelment/revocation of suspension/release of payments in future, in case the hospital fails to render follow-up services to the Aarogyasri patients.

Article 5: Specialties for which empanelment is done:

No. Specialty Service

Available/ Not

Available

Specialist Name

Qualification

SURGICAL SPECIALTIES 1 General Surgery Qualified General Surgeon with post graduate

degree in General Surgery

Well Equipped theatre facility with trained staff Post-op with Ventilator Support SICU Facility Availability of support specialty of General

Medicine, Pediatrics

1a For Laparoscopic Surgeries Surgeon having requisite training and having

performed at least 100 procedures for laparoscopic surgery (documentary evidence to be produced)

2 Orthopedic Surgery Qualified Orthopedic Surgeon Well equipped theatre with C-Arm facility Trained paramedics Well equipped Post-op facility with Ventilator

Support

Round the clock lab support with CT,MRI 3 Gynecology and Obstetrics Qualified Gynecologist Expertise trained in laparoscopic procedure

with minimum 100 performances

Well Equipped theatre Post-op ventilator & Pediatric reconstruction

facilities.

Support services of Pediatrician 4 Ophthalmology Qualified Ophthalmologist, trained vitreo

Retinal and orthotics surgeon

Optometry facility Well equipped theatre facility 5 ENT Qualified ENT Surgeon Well equipped theatre Post-op with ventilator support Audiology support 6 Cardio-thoracic surgery

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CT Surgeon CT theatre facility Cath-Lab Cardiologist support Post-op with ventilator support ICCU Other cardiac infrastructure 7 Plastic Surgery Qualified Plastic Surgeon with Mch in plastic

surgery or other equivalent degree recognized by MCI

Well Equipped Theatre SICU Post-op with ventilator support Trained Paramedics Post-op rehab / Physio-therapy support 8 Neurosurgery Qualified Neuro-Surgeon(M.Ch Neurosurgery

or equivalent)

Well Equipped Theatre with qualified paramedical staff

Neuro ICU facility Post-op with ventilator support Step down facility Facilitation for round the clock MRI,CT and

other support bio-chemical investigations

9 Urology Qualified urologist Well equipped theatre with C-ARM Endoscopic investigation support Post-op with ventilator support esw lithotripsy equipment 10 Pediatric Surgery Qualified pediatric surgeon Well equipped theatre Pediatric and Neonatal ICU support Post op with ventilator and pediatric

resuscitator facility

Support services of pediatrician 11 Surgical Gastroenterology Qualified Surgical Gastro-Enterologist Well Equipped Theatre Endoscope equipment Post op with ventilator support Centre Must have done at least 100

Endoscopic Surgeries

SICU B MEDICAL SPECIALTIES

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1 Critical Care Qualified General Physician with post

graduate degree in General Surgery, Or Equal

AMC with ventilator support 2 General Medicine

Qualified General Physician with post graduate degree in General Surgery, Or Equal AMC with ventilator support

3 Infectious DiseasesQualified General Physician with post graduate degree in General Surgery, Or Equal AMC with ventilator support

4 Pediatrics Qualified pediatrician NICU & PICU fully equipped Round the clock Pediatric / Emergency service

room with Pediatrician

Pediatric resuscitation facility 5 Cardiology Qualified Cardiologist with DM or Equivalent

Degree

ICU Facility with cardiac monitoring and ventilator support

Hospital should facilitate Round the clock cardiologist services

Availability of support specialty of General Physician,& Pediatrician

5a Cardiac Interventions and Procedures Qualified Cardiologist with experience in

interventions and procedures

Fully equipped Cath lab Unit with qualified and trained Paramedics

Must have Backup CT Surgery Unit to perform Cardiac Surgeries

Centre Must have done at least 100 interventions

6 Nephrology Qualified Nephrologists with DM or Equivalent

Degree

Haemodialysis facility AMC and Physician Support. 7 Medical-Gastro Enterology Qualified Gastro Enterologist with DM or

Equivalent Degree.

Endoscopy facility AMC and Physician Support. Centre Must have done at least 100

Endoscopic Procedures

8 Endocrinology Qualified Endocrinologist with DM or

Equivalent Degree.

AMC with ventilator and Physician Support.

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9 Neurology Qualified Neurologist with DM or Equivalent

Degree.

EEG, ENMG, Angio-CT facility for Neurological study.

Neuro ICU Facility with ventilator support. Physician Support. 10 Dermatology Qualified Dermatologist with MD or Equivalent

Degree.

AMC and Physician Support. 11 Pulmonology Qualified Pulmonologist RICU facility Spirometry and bronchoscopy facility Physician Support. 12 Rheumatology

Qualified RheumatologistMICU FacilityPhysician and Orthopaedic SupportPhysiotherapy Support

CCOMBINED SERVICES FOR CANCER THERAPY

1 Cancer Services of qualified Medical Oncologist Services of qualified Surgical Oncologist Services of qualified Radiation Oncologist Fully equipped Radiotherapy Unit SICU

Article 6 - Cashless Services under Package:6.1 The Provider agrees to provide total cashless transaction to the Beneficiary right from his reporting to discharge under the scheme.6.2 Provider agrees to provide treatment as per the packages worked out by the Trust. The package includes consultation, medicine, diagnostics, implants, food, cost of transportation, hospital charges etc. In other words the package should cover the entire cost of patient from date of reporting to his discharge from hospital 10 days after surgery, making the transaction truly cashless to the patient. And under no circumstances shall charge any money extra within the treatment period of package.6.3 The Provider agrees to issue a test requisition slip to the patient which will empower the patient to approach the concerned diagnostic/test centers within the hospital or otherwise and do the tests without any cash transaction. The details of the Tests done and their results will be uploaded in the portal by the RAMCO of the Provider.6.4 Provider agrees to keep all the Aarogyasri patients admitted till 10 days of postoperative period or till the patient recovered satisfactorily in all those cases where operation was performed.6.5 The hospital agrees to the package to be authorized even for those patients who were admitted as non-Aarogyasri out of ignorance but subsequently identified as

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Aarogyasri beneficiary during the course of his/her stay in the hospital. In the meanwhile any payment received from the patient shall be refunded immediately after getting pre-authorization approval and before discharge of the patient from the hospital duly obtaining a receipt from the patient.6.6 Hospital shall assist and facilitate the patient to procure compatible blood for the surgeries and therapies. The hospital shall provide blood from their own blood bank subject to availability within the package. In case of non-availability the hospital shall make efforts to procure from other blood banks, Red Cross, voluntary organizations etc. The hospital shall also issue a copy of the request letter to the patient.

Article 7: Package Rates:7.1 The Package rates are given in the Booklet ( Rajiv Aarogyasri Manual on Surgical & Medical Treatments for Cashless Treatment of BPL Population - 3rd edition) will form a part and parcel of the MOU and which will be the basis and binding for the treatment cost of various procedures and as per the package rates mentioned in Annexure –IV .7.2 The package rates are the maximum rate indicated for each surgical procedure. However, the settlement of the claims will be made on the basis of actual bills submitted by the provider.7.3 Provider has agreed to the continuation of the agreed tariff for the period of this agreement.7.4 In the event of more than one procedure is being undertaken in one sitting other than those of routine/standard components of the surgical procedure, the package amount will be decided by the technical committee in consultation with treating doctor and decision of this committee will be final and binding on the hospital.7.5 Provider under any circumstances will not refuse to undertake procedure on the ground of insufficient package.7.6 In all other disputes related to package rates and technical approvals of pre-authorizations, the matter will be referred to a technical committee of the Trust and decision of the committee is binding on the provider.7.7 The Provider undertake to provide cashless treatment to the beneficiaries for all the complications that are directly related to surgery/therapy and shall ensure best of the treatment for such complications till the final outcome.

Article.8: Cost of evaluation of patients:8.1 The cost of various treatment/tests conducted on the BPL family members who are evaluated but ultimately do not undergo Surgery or Therapies will be borne by the Provider themselves and the Provider will not charge any fee for consultation and investigation from the Beneficiary.Article 9: Quality of Services:9.1 Provider agrees to provide separate and Free OPD consultation. However there will not be any discrimination to Aarogyasri patients vis-a-vis other paying patients in regard to quality of services.9.2 Provider shall agree to provide free diagnostic tests and medical treatment for beneficiaries irrespective of surgery/ Therapy required. 9.3 The Provider will treat Aarogyasri Beneficiaries in a courteous manner and according to good business practices.9.4 The Provider will extend admission facilities to the Beneficiaries round the clock.

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9.5 The Provider will have themselves covered by proper indemnity policy including errors, omission and professional indemnity insurance and agrees to keep such policies in force during entire tenure of the agreement.9.6 Provider will ensure that the best and complete diagnostic, therapeutic and follow-up services based on standard medical practices/recommendations are extended to the Beneficiary. 9.7 The provider agrees to provide quality service to the beneficiary by following standard protocols for diagnosis and treatment. It is also mandatory for the provider to assess the appropriate need and subject the beneficiary for treatment/Procedure.9.8 The provider agrees to provide quality medicines, standard prostheses, implants and disposables while treating the beneficiaries.9.9 The provider agrees to assist and cooperate with the medical auditing team from the Trust / Insurer as and when required. 9.10 The provider agrees to provide video recorded evidence of patient counseling before surgery in order to avoid legal complications / any adverse reaction by patients or Patient’s relatives or by public in the event of unacceptable outcome.9.11 The hospitals Morbidity and Mortality cases will be subject to scrutiny by the Trust/ Insurer. (Refer ANNEXURE-V & XIV)9.12. The provider agrees to take sole responsibility in submitting the patient details online and if any discrepancy is found in this regard the Provider agrees to abide by decisions of EDC.

Article 10 Services of Medical Coordinator:

Provider will have a Medical Officer/Medical Officers designated as Rajiv Aarogyasri Medical Coordinator/s (RAMCO) for the scheme to coordinate with Trust through Aarogyamithra. The provider agrees to submit the details of appointed RAMCO’s as per the ANNEXURE XXII. The provider should promptly inform the insurer about change if any in the RAMCO designated during the tenure of the agreement.The following will be the responsibilities of RAMCO (Rajiv Aarogyasri Medical Coordinator): 1. He/She will ensure that all required evaluation including diagnostic tests are done

free of cost for all beneficiaries and the details of the same along with reports are captured in the Trust portal.

2. He/She will upload the OP/IP status of the patient.3. He/She will guide the patient in all aspects and sign the investigation request.4. He/She has to cross check whether diagnosis is covered in the scheme. If doubtful

about the plan of management then should coordinate with treating specialist along with Package list as specified in the Rajiv Aarogyasri Manual on Surgical & Medical Treatments for Cashless Treatment of BPL Population – 3rd edition.

5. He/She should facilitate the admission process of Patient without any delay.6. After admission He/She will collect all the necessary investigation reports before

sending for approval.7. He/She will upload the admission notes and preoperative clinical notes of the patient.8. He/She will ensure that preauthorization request is sent only for those who are on

bed (IP).9. He/She will ensure before sending Preauthorization that all documents like white

card, Patient photo and also necessary reports like CT Films, X-Ray films, Angio CD etc. are uploaded in the system.

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10. He/She will coordinate with insurance and trust doctors as need arises.11. Preauthorization kept pending from Insurance and trust will be verified on a regular

basis and necessary corrections to be done by RAMCO.12. He/She will furnish daily clinical notes (pre Operative and Post-operative).13. He/She will upload 3 Photographs of the Patient taken preoperative bedside,

immediate post-operative showing operation wound and at the time of discharge.14. He/She will update surgery and discharge details and hand over signed copy of the

summary along with follow-up advice in preprinted stationary supplied.15. He/She will ensure free follow – up consultations, routine investigations and

distribution of drugs to be supplied by the Provider to the beneficiaries. And also refer ANNEXURE-VI.

16. He/She will ensure to update the details of on bed status of patients time to time as per the format (Refer ANNEXURE-XX) on the display board placed at the Aarogyamithra Kiosk / reception desk.

17. The Provider will have a Data Entry Operator and each data entry operator will be linked to the respective RAMCO and the final responsibility of the data fed by the data entry operator will be vested on RAMCO of the Hospital. The provider agrees to submit the details of Data Entry Operators as per the ANNEXURE XXV.

Article 10.1 Mode of Communication10.1 (i) The Provider agrees to use the Closed User Group (CUG) mobile phone given

by insurer to RAMCOs & AMCCOs exclusively for the purpose official communications related to Aarogyasri Scheme. Any mis-utilization of CUG by the RAMCOs & AMCCOs the insurer reserves the right to initiate action against the service Provider.

(ii) The Provider agrees to use only Aarogyasri Messaging Services provided on the Web Portal for any kind of official communications related to Rajiv Aarogyasri scheme. The Email-Ids of RAMCOs & AMCCOs provided by the Trust/Insurance will be used as their communication method.

Article 11 Documentation and MIS11.1 The provider will ensure that documentation of Aarogyasri patients are done using standard formats supplied/available online such as admission card, referral card, investigation slip, discharge summary etc.11.2 (i) Trust / Insurer reserves the right to visit the Beneficiary and check his medical

data with or without intimation as and when required. (ii) The Provider will allow the General Managers / Deputy General Managers /

Field staff / Doctors / vigilance officials and other officials from the Trust and Insurance Company to inspect the hospitals without obstruction and co-ordinate with them during Surprise and Regular Inspections.

11.3 Provider will furnish periodical reports to Trust/insurer on the progress of the scheme as per the formats prescribed for this purpose.11.4 Provider will not give any document to facilitate the Aarogyasri patient to obtain any other relief like CMRF etc. Provider will not claim any other relief for the procedures covered under the scheme. Any deviation in this regard may attract Delisting of the hospital. 11.5 The Provider agrees to keep printouts of all online documents in the case sheet and make available as and when required for verification by field staff/ doctors of the Trust/Insurance.11.6 The Provider agrees to maintain the patient data as per the standard protocols.

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11.7 The Provider shall communicate the data related to Aarogyasri patient deaths occurred in the hospital to Trust/Insurer immediately in the prescribed format annexed herewith. Refer Annexure- XXIX

Article 12 Display of Boards & Banners12.1 Provider agrees to display their status of preferred Provider of Rajiv Aarogyasri Community Health Insurance Scheme at their reception/admission desks.12.2 Provider agrees to display their status of specialties empanelled in Rajiv Aarogyasri Community Health Insurance Scheme at their reception/admission desks.12.3 Provider agrees to display availability of beds in the hospital and also display specialty wise bed occupancy under Rajiv Aarogyasri Community Health Scheme at their reception/admission desks. (Refer ANNEXURE- XX)12.4 Provider agrees to make available of the list of diseases with package rates covered under Aarogyasri community Health Insurance scheme in the form of Booklet supplied by the Trust/Insurer at their reception/admission desks.12.5 Provider agrees to display other materials supplied by Trust / Insurer for the ease of Beneficiaries.

Article 13 Rajiv Aarogyasri Kiosk and Aarogyamithra Services13.1 The Provider will allow Rajiv Aarogyasri Assistance Counter / Kiosk to be established at the reception of the Provider free of cost. (Photograph of the space annexed herewith (Refer ANNEXURE – I)13.2 The Provider will provide following infrastructure and network facility to the counter: P.C, Printer, Scanner, Digital camera, Webcam, Barcode reader, Mike, Speakers, Stationary etc. (Refer ANNEXURE – XVIII). The System and other peripherals should be provided exclusively for the use of Aarogyamithra who can use the resources at any point of time.13.3 The Provider will provide a dedicated 2 MB broadband connectivity to the Computer to be exclusively used by the Aarogyamithra to access the web for online MIS, e-preauthorization etc.13.4 The Provider will allow Aarogyamithra access to the wards and patients’ data to facilitate onward transmission to the Company for e-pre-auth, claims, correct MIS etc.13.5 The Provider will update the date of surgery, discharge /death of the beneficiary in the Trust portal.13.6 The Provider will intimate Aarogymithra and RAMCO regarding emergency admissions of the Beneficiary during non office hours.Article 14 Preference to Beneficiaries:14.1 The provider agrees not to deny admission for the beneficiary for want of Preauthorization approval.14.2 The Provider agrees to provide a separate ward for Rajiv Aarogyasri Beneficiaries.14.3 The Provider agrees to provide separate Operation Theatre and weekly schedules for the surgeries/ therapies to be performed for the Beneficiaries.

Article 15 Capacity for Surgeries:15.1 The Provider agrees to handle a minimum number of cases in each specialty including trauma cases based on their available infrastructure as under:

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15.2 The Provider agrees to submit the vacancy level in pre operative wards, ICU, Post operative wards and also upload the same in the Trust portal on a daily basis.

Article 16 Health Camps:16.1 The Provider will conduct free Health camps at least once a week at the place specified by the Trust to identify the members of the BPL families who may require surgeries covered under the scheme as per the schedule given by the Trust/for such surgeries. The camp policy as given in Annexure II will be scrupulously followed.16.2 The Provider will carry necessary diagnostic equipment such as ECG, Echo, Ultrasound etc. to these free Health camps. 16.3 The Provider will provide services of concerned specialists namely Cardiologists, CT Surgeon, Neurosurgeons, Urologists, Oncologists, Gynecologists, Plastic Surgeon,

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CATEGORY SPECIALTYCapacity to admit number of patients/ Day(Bed Strength)

A MEDICAL SPECIALTIES

Critical CareGeneral MedicineInfectious DiseasesPediatrics Neonatal Intensive Care Pediatric Intensive Care Pediatrics(General)Cardiology(Medical Management)NephrologyNeurologyEndocrinologyMedical GastroenterologyDermatologyRheumatologyPulmonology

B SURGICAL SPECIALTIESGeneral SurgeryOrthopedicsENTOphthalmologyGynecology and ObstetricsCardiac and Cardiothoracic SurgerySurgical GastroenterologyGenitourinary SurgeryNeuro SurgeryPediatric SurgeryPlastic Surgery

C SPECIAL SERVICESCancer Medical Oncology Surgical Oncology Radiation Oncology*

Pediatric Surgeon, General Physicians to the camp to facilitate proper evaluation of the patients.16.4 The Provider will submit the camp confirmation and indent (Annexure-III) online as given in camp policy in the prescribed format to Trust/Insurance at least one week in advance of the stipulated date.16.5 The Provider will inform all the stakeholders such as district Administration, concerned public representatives, PHC / AH / DH staff etc well in advance for successful conduct of the camp. 16.6 The Provider will spread awareness about the camp through Publicity in coordination with District coordinator, Regional coordinator, PHC staff and Aarogyamithras.16.7 The Provider will provide patient data to Trust/Insurance in the prescribed form at the end of the camp.16.8 The Provider will enter the details of the patients screened and referred at the camps on the Trust website on the same day of the Camp.16.9 The Provider will coordinate constantly with the Health camps cell of the Trust in all matters related to Health camps.16.10 The patients referred from the camp will be followed up and transported to the Hospital within 10 days of the camp unless the patient is not willing, in which case the same should be recorded and updated in the Website. 16.11 Provider will have an Officer designated as Aarogyasri Medical Camp Coordinator (AMCCO) for the scheme to coordinate with Trust/Insurance through Aarogyamithra. The provider agrees to submit the details of appointed AMCCO’s as per the ANNEXURE XXIV.The provider agrees to inform the insurer & Trust about the change in the AMCCO designated if any, during the tenure of the agreement.The provider will give the full time services of Aarogyasri Medical Camp Coordinator (AMCCO) to coordinate all activities related to camps and patient follow up from camps.The following will be the responsibilities of Aarogyasri Medical Camp Coordinator (AMCCO):

• Confirmation of camps online and indenting online• Carrying out the IEC activities within camp area at least 7 days before the camp date.• Providing facilities like shamianas, chairs, screening enclosures• Providing common medicines in the camps.• Arranging Health Education Exhibits and Pamphlets etc., in the camp.• Arrange for distribution of incentives to the medical officers.• Coordinating and ensuring participation of specialists.• Arranging the diagnostic equipment• Coordinate with PHC doctors/Government Doctors, Public Representatives, SHG groups and Local Administration. • Raising claims online for the camps conducted.• Follow – up of patients referred from Camps as per clause 16.10And other responsibilities mentioned in ANNEXURE-XV

Article 17 Admission of Beneficiary:17.1 Request for examination and if necessary hospitalization for surgical procedures on behalf of the Beneficiary will be made by the “Rajiv Aarogyasri Help Desk” at PHC/ Government Hospital or by the “Rajiv Aarogyasri Assistance Counter/ Kiosk” at Network Hospital.

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17.2 Aarogyamithra at Rajiv Aarogyasri Assistance Counter/ Kiosk at the Network Hospital will coordinate with the Provider from the time of admission till discharge after the surgical procedure.

Article.18 e-Pre-Authorization:

18.1 Pre-authorization request will be sent only after admission and the patient will be there in the hospital as inpatient till final decision on the Preauthorization is made.18.2 (i) The Provider will submit the e-pre-authorization, after admitting the patient as

in- patient, on the Aarogyasri Website completely in all aspects including the signed copy of consent of the Patient.

(ii) All relevant test reports along with Digital photograph of the Beneficiary taken in the hospital should also be uploaded. Catheterization CD, MRI films, X-rays, biopsy reports will be uploaded, cytology and biopsy reports / slides should be submitted.

(iii) The Provider agrees to upload the clinical photographs as required under the scheme taking due care of confidentiality of patient and follow the standard medical practices & ethics.

18.2a Insurer undertake to approve the Preauthorization in consultation with the Trust indicating the relevant package rates within 12 working hours of the receipt of the request for pre-authorization form as well as the required data and information online.18.2b The Provider agrees to update the surgery online immediately after performing the Surgery. However, the validity period of the pre-authorization is 14 days from the date of approval. The Provider agrees to update clinical notes of ALL cases (both Pre & Post pre-authorization notes) in the Website on daily basis. If the surgery / therapy is not updated within 14 days after approval of pre authorization will automatically get cancelled in the Aarogyasri Portal. The provider should obtain fresh approval for the cancelled pre-authorizations by mentioning valid reasons and the Insurer/Trust reserves the right to approve the request of pre-authorization. After Approval of pre-authorization, if the patient is not found on bed at the time of routine check by officials of Trust/Insurer and in case the provider unable to present the patient during the routine check by officials of Trust/Insurer, the Trust/Insurer reserves the right to cancel the Preauthorization immediately without any intimation.18.2c If the provider is not able to conduct the operation within a reasonable time for any reason other than medical such as non availability of beds or specialists, the Provider will arrange for the operation to be conducted at any other appropriate Network Hospitals in consultation with Insurer. 18.2d The provider agrees that the approval of Pre-authorization by Trust/Insurance is mere approval for eligibility of case for Assistance under scheme and should not be construed as approval of choice of the treatment & outcome consequences thereof which is sole responsibility of treating Doctor.18.2e Any deficiency in documentation & ONLINE updation of data and protocols by the Provider which may lead to pending of Pre-authorization approval, the responsibility for such delay leading to delay in treatment & outcome is solely responsible of the Provider.18.2f The provider agrees that any Rejection of Pre-authorization shall not be construed as denial of treatment to the patient and outcome thereof, it is a mere rejection of assistance under the scheme guidelines. The provider agrees to exercise best of his judgment and counsel the patient about the alternate ways of providing such care including the option of referring the patient to Govt. Institution where such facility exists.

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18.3 Preauthorization preferably will be given to the network hospital whichever does the preliminary screening either at the Medical camp or at the hospital. Second pre-authorization for the same patient from different network hospital will not be entertained for the same procedure unless medically warranted or surgical procedure is unduly delayed by the first hospital without proper medical grounds.18.4 Insurer reserves the right to disallow the claim if the Surgery/Therapy is performed before any approval from the Insurer/Trust and pre-authorization is obtained at a later date keeping the Insurance / Trust in dark about the surgery / therapy.18.5 The provider agrees to send the enhancement requests before the discharge of the patient through E-mail enhancements@aarogyasri.org or by fax and follow the enhancement guidelines (ANNEXURE- XXI) and enhancement module manual in the booklet (Aarogyasri manual for Surgical and Medical treatments for Cashless Treatment of BPL Population – 3rd edition). The Provider agrees to abide by the decision of Technical Committee and shall extend cashless facility to the patient. 18.6 The provider agrees to obtain emergency Telephonic Approval for emergency cases only. The Insurer/Trust reserves the right to cancel the Emergency telephonic approval, if the provider fails to update the pre-authorization online within 72 hours of Emergency telephonic approval. The provider also agrees to perform the surgery / therapy obtained through telephonic intimation within 24 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. (Refer Annexure –XXVII)

Article.19 Transport of Patients:19.1 The Provider agrees to transport or bear the cost of transport charges (To & fro) incurred by the beneficiary and agrees to arrange the same at time of discharge and obtain acknowledgment from the patient accordingly. The Provider agrees to obtain signature of beneficiary on the acknowledgment sheet generated from the portal and upload the scanned copy to Aarogyasri Web portal.

Article 20 Free Food to patients:20.1 The Provider agrees to provide free food to the patients as envisaged in the package rates either through in-house pantry or by making alternate arrangements like supplying from nearby canteen.

Article 21 Discharge and Follow up:21.1 Intimation of the impending discharge of the Beneficiary need to be advised to Aarogyasri Assistance Counter at least one day before the discharge of the patient.21.2 The discharge has to be done in the presence of RAMCO and Aarogyamithra concerned and update the details ONLINE.21.3 At the time of Discharge the transportation cost to and fro has to be reimbursed to the Patient, if the Hospital has not provided the transportation. The acknowledgment of receiving the amount for transportation has to be generated from the Trust portal and the signed copy has to be uploaded.21.4 Discharge summary will be generated from the Trust portal in a pre-printed stationary to be supplied. The Discharge summary will consist of all the treatment details of the Patient at the Hospital and the follow up regime for the Patient including consultation and medication. 21.5 All the patients must be provided with follow-up medicines after discharge by the provider as part of the package.

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21.6 If the same Patient is coming back to the Hospital, the follow up details have to be uploaded in the Trust portal. 21.7 Satisfaction letter of the Patients has to be generated from the Trust portal and the signed copy has to be uploaded.21.8 The RAMCO & Aarogyamithra should counsel the patient for all the precautions to be taken for the post-operative care.21.9 All patients who require follow-up medicines will be advised by the provider to come back on 11th day of discharge for first follow-up mandatory. The date of first follow-up will be generated by the Trust portal along with the discharge summary.21.10 The subsequent follow-ups for the above cases will be as per the follow-up guidelines (Refer ANNEXURE- VI).21.11 The provider will agree to provide follow-up services for a period of ONE YEAR under the Scheme from the date of reporting on or after 11th day post discharge and even in case of Provider status being ‘Delisted or Suspended’ under the scheme by Empanelment and Disciplinary committee (EDC) as per Article No.26.21.12 The provider will provide free post-transplant immunosuppressive therapy for a period of six months from date of surgery (1st to 6th month), irrespective of agreement period for all cases of renal transplant within package. The provider will do cashless post-transplant immunosuppressive therapy for the remaining period of six months (7th

to 12th month) under Aarogyasri II.21.13 The provider will agree to provide free post surgical physiotherapy services, wherever required for the agreement period.

Article 22 Billing Procedure /Checklist for the Provider at the time of Patient’s discharge:22.1 It is admitted and agreed that the Provider is aware that this MoU has arisen for the purpose of implementation of the Rajiv Aarogyasri Community Health Insurance Scheme (Aarogyasri I & II) intended for Below Poverty Line families in specified Districts of Andhra Pradesh and accordingly the Provider will in no circumstance charge or seek any payment from the Beneficiaries but will look only to for indemnity, and that too only to the limits/schedule of fees in respect of procedures referred to earlier and agreed to under this MOU. 22.2 Signature or the LTI of the patient / Beneficiary will be obtained on final hospital bills and the discharge form.22.3 The provider will submit the following to: Original discharge summary, original investigation reports, all original prescriptions, Procedure CD’s, MRI films, X -rays, Post Operative slides with Biopsy report, 3 Photographs of the patient taken preoperative bedside, immediate post-operative showing operation wound and at the time of discharge, Case Sheet with Operation Notes, Break up of the bills (Room Rent, Investigations, procedure charges & pharmacy receipt) etc. These are to be made available to for Claim payment, while submitting the bill. The copies of the discharge summary signed by the Beneficiary will be uploaded in the web. A summary of the bills raised will also be uploaded.22.4 Letter of Satisfaction from the patient should also be obtained and sent along with the bills to in prescribed format.22.5 Provider should ensure that Chemo Therapy Drugs are physically administered to the Patients. Provider should produce bills by coating batch no. and attaching empty vials & ampoules with intact labels.

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22.6 The Provider will have an Officer designated as Billing Head in order to follow the process the online work flow. The provider agrees to submit the details of Billing Head as per the ANNEXURE XXIII.

Article 23 Payment Terms and conditions:23.1 Insurer agrees to pay all the eligible bills within 7 working days, subject to submission of all supporting documents including post-operative investigations and reports as required online and the Photocopies of daily progress report and ICU charts should be sent by courier. 23.1a The payments to the Provider are made by the Insurer after deducting Taxes (TDS) as per prevailing IT Rules, and accordingly Insurer will issue the Form No.16A at the end of Financial Year. Provider hereby agrees to comply all the formalities required in fulfilling regulations of Income Tax Dept. (Refer ANNEXURE –XXVI)23.2 The provider agrees to submit the core banking number IFSC code to the insurer to facilitate electronic fund transfer for settling the claims. (Refer ANNEXURE – XIX)23.3 The Provider agrees to submit all the claims for the surgeries/Treatments performed within 60 days from the date of discharge of patient. 23.4 The provider agrees to perform Surgeries/Treatment within 30 days of the date of expiry of this agreement for all the Pre-authorizations obtained during the policy period and submit the claim as per clause 23.3 above.23.5 The Trust/Insurer reserves the right to cancel the claims if the Provider fails to submit the claims within time mentioned in clause 23.3.

Article 24 Limitations of liability and indemnity:24.1 The Provider will be responsible for all commissions and omissions in treating the patients referred under the scheme and will also be responsible for all legal consequences that may arise. Insurer/Trust will not be held responsible for the choice of treatment and outcome of the treatment or quality of the care provided by the Provider and should any legal complications arise and is called upon to answer, the provider will pay all legal expenses and consequent compensation, if any.

24.2 The Provider admits and agrees that if any claim arises out of` alleged deficiency in service on their part or on the part of their men or agents, then it will be the duty of the Provider to answer such claim. In the unlikely event of Insurer being proceeded against for such cause of action and any liability was imposed on them, only by virtue of its relationship with the Provider and then the Provider will step in and meet such liability on their own.

24.3 Notwithstanding anything to the contrary in this Agreement, neither Party will be liable by reason of failure or delay in the performance of its duties and obligations under this Agreement if such failure or delay is caused by acts of God, Strikes, lock-outs, embargoes, war, riots civil commotion, any orders of Governmental, Quasi-Governmental or local authorities, or any other similar cause beyond its control and without its fault or negligence.

24.4 The Provider undertake for applicability of terms and conditions mentioned herein for all the phases in- lieu of this MOU.

24.5 The mere Preauthorization approval of case by Trust/Insurer based on the data provided by the Network Hospitals shall not be construed as final medical opinion with regards to Diagnosis & Treatment of choice. The treating Doctor & Network hospital

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shall be solely responsible for the final diagnosis of disease, choice of treatment employed and outcome on such treatment.

24.6 Provider admits and agrees that if any claim, suit or disciplinary actions by Empanelment and Disciplinary Committee (EDC) as per clause No.26.1 arises due to any commissions or omissions of their employees including RAMCO,AAMCO, Billing Head, Data Entry Operator or employees outsourced by them, Provider will be liable for such claim/suit or Disciplinary action.

Article 25 Confidentiality:

All the stakeholders undertake to protect the secrecy of all the data of Beneficiaries and trade or business secrets of and will not share the same with any unauthorized person for any reason whatsoever within or without any consideration.

25.1 The provider agrees to protect the confidentiality under this agreement and ensures not to recruit ex-employees of insurer anytime during this agreement and also for a further period of one year from the date of expiry of this agreement.

25.2 The Provider agrees to protect the confidentiality of the patient data including that of the clinical photographs and take due care to follow the standard medical practices while obtaining such photographs, under any circumstances Trust/Insurer cannot be held responsible for lapse in confidentiality and protecting the information of the patient in the hospital.

25.3 The Provider undertake to handle the patient data diligently and shall not share or give access to employees of the hospital or to the outsiders under any circumstances within the hospital or outside.

Article 26 Disciplinary Actions:26.1 Any deficiency in service by the empanelled hospitals (Provider) or non-compliance of the provisions of MOU will be scrutinized by the Empanelment & Disciplinary Committee (EDC) constituted as per the Aarogyasri Health Care Trust Resolution No.134/2009 comprising of representatives from the Trust and Insurer and make deliberations to suspend / de-list / stop payments or any other appropriate action based on the nature of the complaint against the Provider. The Provider shall abide by the decisions made by the EDC and Trust.

Article 27 Jurisdiction:27.1 Any dispute arising of this MOU will be subject to arbitration as per Arbitration Act

and subject to the jurisdiction of Andhra Pradesh courts only. 27.2 Any amendments in the clauses of the Agreement can be effected as an addendum, after the written approval from both the parties.

Article 28 Non-exclusivity:28.1 Insurer reserves the right to appoint other Provider/s for implementing the packages envisaged herein and Provider will have no objection for the same and vice-versa.In witness thereof this agreement executed by or on behalf of the parties on the day and year mentioned above.

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Signed and delivered by:

Provider: ____________________________________________________________________

Through it’s CEO/Superintendant/Managing Director

Sri/Smt.__________________________________

sign ______________________________

In presence of Sri/ Smt._____________ Sign ________________________________

Trust:Aarogyasri Health Care Trust:

Through it's Executive Officer Sri/Smt____________________________________

Sign __________________________

In presence of Sri/ Smt ____________________Sign ___________________________

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Annexure 1

AAROGYASRI HEALTH CARE TRUSTRAJIV AAROGYASRI COMMUNITY HEALTH INSURANCE SCHEME

PHOTOGRAPH OF SPACE FOR AAROGYAMITHRA KIOSK

Name of Network Hospital:

Address:

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Affix the Photograph of the space provided in the hospital for establishing Aarogyamithra Kiosk

Annexure II

Aarogyasri Health Care Trust

HEALTH CAMP POLICY

Health camps are the main source of mobilizing the beneficiaries under the scheme. All the Network Hospitals are conducting regular free health camps under the Rajiv Aarogyasri Community Health Insurance Scheme. These camps are to be held as per the schedule and place given by the Trust. It may be further noted that 50% referrals are from camps. The importance of the camps vis-à-vis the scheme and common health problems is increasing day by day. The camps are also be used to provide free medical advice and medicines to the rural people. Effective conduct of health camps is the key to success of Rajiv Aarogyasri Community Health Insurance Scheme.

Government realizing the important role played by the camps desires to include the following activities on a regular basis:

Activities

1) Promote IEC activity by the network hospitals through• Pamphlet Distribution• Public Address System/ Mike announcements in Autos• Dandora/ beat of tom-tom• Playing of Audio-Visual media (Casettes, Audio CDs and DVDs)• Scroll in local cable networks.• News/Advertisements in local dailies• Posters• Banners• SHG meetings• Village meetings• Exhibits on hygiene, general health, prevention of communicable

diseases etc.• Exhibits on early detection and prevention of chronic diseases• Any other activity chosen by the hospital

2) Improve facilities in the camp by • Providing shade for waiting patients by erecting shamianas

• Providing pedestal fans• Sitting arrangements for waiting patients by providing sufficient number

of chairs• Drinking water for patients• Screening enclosures for patients

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• Snacks• Any other activity chosen by the hospital

3) Provide treatment for common ailments and common drugs in the camps and prevent spread of communicable diseases.

• Provide consultation for ailments other than those covered under the scheme.

• Provide common drugs for general ailments as indicated in the list below:

LIST OF COMMON DRUGS TO BE PROVIDED IN CAMPS

Category

S.No.

Form Drug Strength Minimum Qty.

I Anti inflammatory/

antipyretic/analgesic

1 Tab Ibuprufen 400mg 5002 Tab Paracetomol 500mg 1000

3 Tab Aspirin 300/500 mg

500

4 Tab Diclofenac Sodium

100 mg 1000

II Anti-Allergic 5 Tab Chlorpheniramine Maleate

4mg 5000

III Anti-Amoebic

6 Tab. Metronidazole 400 mg. 800

IV Anti-Helmenthic/Deworming

7 Tab Albendazole 400 mg 100

V Antibotic 8 Tab Norfloxacin 400 mg 10009 Tab Ciprofloxacin 500 mg 50010 Cap Ampicillin 250mg 500

VI H1 antagonist

11 Tab Ranitidine 150 mg 1000

VII Antacid 12 Tab Antacid 2000VIII Vitamins&Iro

n supplement

13 Tab Multivitamin 200014 Tab. Iron+Folic Acid 200015 Tab B-Complex 100016 Tab. Vit.C 500mg 100017 Cap A&D 2000

IX For Children 18 Syrup

Paracetomol 125 mg/5ml

20

19 Syrup

Ampicillin 125mg/5ml

10

20 Syrup

Antitussive 20

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• Hospital shall carry at least 10 types of drugs from the above list and have at least one drug from each category.

• Distribution of all drugs for children (Category-IX) is mandatory• Minimum stock as stated in the list of common drugs must be carried to the

camp. However hospitals are free to distribute more number of drugs and left over stocks if any from other camps.

• Minimum of Rs.1500 worth medicines must be carried to each camp.• Hospitals may carry generic drugs instead of proprietary preparations to

keep the cost of medicines low

4) Network Hospital to provide professional incentives to the Government Doctors participating in the camp to encourage their active participation and cooperation. Each Medical officer has to be given an incentive of Rs 250/- camp. At least two medical officers, drawn from the PHCs/CHCs/AHs/Government hospitals shall participate in the camp organized by single network hospital and at least four medical officers, drawn from the PHCs/CHCs/AHs/Government hospitals shall participate in the camp organized by two network hospitals. Each Network hospital shall pay the incentive for two medical officers.

II. ALLOCATIONS

In order to encourage the above activities in the camps by Network Hospitals, Government have decided to provide financial support to the Hospitals through Trust to the tune of Rs.5000 for each Camp and activity wise allocation of the said amount is as stated below:

S.No. Activity Amount allocated in Rs.

1 IEC Activity 1500

2 Basic necessities to patients such as Shamiana, Chairs, Water, Fans, Snacks etc.

1500

3 Providing common drugs to the patients as indicated in the list

1500

4 Incentive to Government Medical Officers

500

Total 5000

The detailed guidelines with regard to indent, approval and utilization of the above amount are given below:

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III. CONFIRMATION OF CAMPS, INDENTING, APPROVAL, ORGANISING, CLAIMING AND REIMBURSEMENT OF AMOUNT:

• The entire process of intimation, confirmation, indenting, details of camp organization and claiming of money will be through the ‘health camp’ module in the Trust website (www.aarogyasri.org). The screen shots and the detailed narration of the process are given in Annexure 2.

• The trust will communicate the schedule of the camps well in advance and the same will be available online in the login of the hospital for confirmation.

• Confirmation and indenting : Hospital shall send update in the website the confirmation for each camp well in time as stipulated by Trust. The details of doctors and paramedics attending the camp and equipments being carried shall also be indicated. Along with the confirmation, the network hospitals shall put up the indent for each camp online detailing the following:

(i) Details of IEC Activities with specific proposals and estimated amount.(ii) Details of facilities to be provided for the camps with specific

proposals and estimated amount.(iii) Details of common drugs to be distributed in the camps with

specific quantities and estimated amount.(iv) Incentives to be given to the Government medical officers with the

names of the Medical officers tied up for the camp.• Approval : Based on the indent the Trust will approve the amount subject to

the maximum of Rs 5000 per hospital per camp. The approval status can be viewed online. Please notice that the approved amount will be denied in case of rescheduling of camps after confirmation.

• Organizing the camps: The hospital shall conduct the camp as per the schedule and by undertaking the activities as given in the indent. The hospitals shall ensure that an Aarogyasri Medical Camp Coordinator (AMCCO) is earmarked for the purpose and is send at least a week in advance to the camp area to undertake IEC activities as planned and arrange for the facilities to be provided for the camps. The hospital coordinator shall ensure that the schedule of the camp is informed to all concerned in the local area of the camp including the people’s representatives. The following documentation have to be done during the camp:

(i) Each patient has to be given an outpatient-cum-prescription card (available with Aarogyamithras – Specimen given at Annexure -A). The details of medicines to be disbursed shall be mentioned in this card.

(ii) Those patients who are treated as outpatients shall be given medicines as noted in the outpatient-cum-prescription card. The details have to be mentioned in the drug dispensing register and the signature/ thump impression of the patient shall be obtained. (Annexure B). The same shall be scanned and uploaded at the time of claim of camp amount

(iii) Those patients who are referred shall be given Rajiv Aarogyasri Community Health Insurance Scheme Referral card with the details of date for reporting to the hospital, place of appointment,

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name of consultant and mobile number of network Aarogyamithra. (available with Aarogyamithra– Specimen given at Annexure -C)

(iv) The details of all outpatients and referred patients will be recorded by the Aarogyamithra in the camp register in triplicate (available with Aarogyamithra – Specimen given at Annexure -D). A copy of the same duly signed by the government Medical Officer, Aarogyamithra and Network hospital doctor shall be kept with the Network Hospital and the same shall be scanned and uploaded at the time of claim of camp amount.

(v) At the end of the camp the incentive shall be given to the participating government medical officer and the acquaintances obtained in the prescribed proforma (Annexure E)

(vi) The Aarogyasri Medical Camp Coordinator (AMCCO) of the Network hospital shall also take a declaration (Annexure F) as to the successful conduct of the camp signed by the Medical officer of the concerned PHC of the venue of the camp. The Aarogyamithra of the PHC shall also sign the same. The Network hospital shall upload the same at the time of claim.

• Claim : Hospital shall make the claim online on a monthly basis for the camps held during that month. Hospital shall upload and submit Utilization certificates (Annexure G). Hospital shall also upload and submit bills, drug dispensing registers, details of IEC activity, photographs of the camp and IEC activities and receipt of payment of Incentives to the medical officers participating in the camp in prescribed proforma annexed.

• Reimbursement : Trust based on uploaded and submitted documents will reimburse the total amount once in a month through online transaction.

IV. ROLE OF DISTRICT ADMINISTRATION IN CONDUCTING THE CAMPS:

The following steps may be taken by the District Administration for the successful conduct of the camps:

1. Spreading awareness on the camps through all possible means. 2. All public representatives including Ministers, MPs, MLAs, MLCs, ZP chairperson, ZPTCs, MPTCs, Sarpanchs, other members of PRIs and all people’s representatives may be informed of camp schedule in advance so that they participate in medical camps. The camp can be inaugurated by local MLA or by other people’s representative depending on availability. Some time of the camp can be earmarked for inauguration.3. Drinking water for patients may be arranged through Panchayath Secretaries and Aarogyamithra/s.4. Minimum facilities like drinking water and working food for doctors and staff participating in the camp may be arranged through the Aarogyamithra/s or the local medical officers. The cost of this will be borne by network hospitals.5. Medical Officers in the nearby PHCs and government hospitals shall also attend camps for general check-up. (In those camps where only one network hospital is participating two medical officers shall be deputed and where two network hospitals are participating four medical officers shall be deputed)

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6. The DMHOs shall take necessary steps to distribute common medicines in camps.7. The patients referred from the camps shall be followed up to report to the network hospital. The Aarogyamithras (minimum two per camp if one network hospital is participating and four per camp if two network hospitals are participating) will ensure that details of date for reporting to the hospital, place of appointment, name of consultant and mobile number of network Aarogyamithras are given to the referred patients in the camp itself.8. The District Coordinator of the Trust and the District Coordinator of the Insurance Company shall speak to the Aarogyasri Medical Camp Coordinator (AMCCO) of the network hospital and ensure that all the activities mentioned above are taking place in time and as planned. The details of medical officers and Aarogyamithras participating in the camps shall also be given to the Aarogyasri Medical Camp Coordinator (AMCCO).

= = =

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Annexure – III

Rajiv Aarogyasri Community Health Insurance SchemeHealth Camp

Health Camp Indent form (to be submitted online)

Name of the Network Hospital:

Date of Camp:

Place of Health Camp Venue:

Mandal : District :

Name of AMMCO Phone Number:

A. Details of Specialists / Doctors attending the campS No Name of the Specialist / Doctors Specialty

B. Details of Paramedical Staff / Other Staff Participating in the CampS No Name of Paramedical Staff / Other Staff

C. Details of Diagnostic Equipment CarriedS No Name of the Diagnostic Equipment

D. Details of Vehicles carried to the campS No Description of Vehicle Registration Number

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E. Details of IEC Activities:

S No Details of Advertisement/Awareness/Publicity for the medical camp

Estimated Amount

Approved Amount

1 Pamphlets to be distributed2 Public Address System / Mike announcement in

Auto rickshaw3 Dandora / Beat of Tom-Tom4 Playing Audio visual Media ( Cassettes, CD’s &

DVD’s)5 Scroll in local cable network6 News/Advertisements in local dailies7 Posters8 Banners9 SHG Meetings10 Village Meetings11 Exhibits on hygiene, public health, Prevention of

communicable diseases12 Exhibits of early detection and prevention of

chronic diseases13 Others

S No Description Estimated Amount

Approved Amount

1 Details of Exhibits if any2 No of Pamphlets distributed

Campaign Date in villages

From Date: To Date:

Villages to be covered:

II: Details of Facilities to be provided for Health Camp

S No Details of Facilities to be provided for Health Camp

Estimated Amount

Approved Amount

1 Provide shade for waiting of patients by erecting Shamiana along with size ( Yes/No)

2 Providing Pedestal Fans3 Sitting arrangements for waiting patients by

providing sufficient no of chairs ( No of Chairs )

4 Drinking Water for patients5 Screening enclosures for patients6 SnacksIII: Details of common drugs to be distributed

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S No

Category Name of the Drug

Quantity Being carried

Estimated Amount

Approved Amount

1 Anti inflammatory/antipyretic/ analgesic

2 Anti-Allergic3 Anti-Amoebic4 Anti-

Helmenthic/Deworming5 Antibiotic6 H1 antagonist7 Antacid8 Vitamins & Iron supplement

9 For ChildrenParacetamolAmpicillinAntitussive

IV: Incentives to be paid to the Govt Medical OfficerS No

Name of the Medical Officer Phone Number Incentive to be Paid

12Details of Aarogyamithra participating in the campS No

Name of the Aarogyamithra Phone Number

12Total Estimated Amount:

Name of the AMMCO: Name of RAMCO:Signature: Signature:

Name of the Aarogyamithra SignatureDate:

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S No Head Estimated Amount Approved Amount1 IEC Activities2 Facilities to be Provided3 Common Medicines4 Incentives

Total

Annexure – IV

RAJIV AAROGYA SRI COMMUNITY HEALTH INSURANCE SCHEMEPACKAGES

GENERAL GUIDELINES ON THE PACKAGES.1. The package includes:

• Consultation, medicines, diagnostics, specialist services• Implants, grafts, prosthetics.• Food.• Cost of transportation • Hospital charges etc.

In other words the package should cover the entire cost of treatment of the patient from date of reporting to his discharge from hospital and 10 days after discharge and any complications while in hospital, making the transaction truly cashless to the patient. The post-operative hospital stay in all surgical procedures shall be minimum of 10 days except in case of interventions and chemotherapy for cancers.

2. Hospital shall conduct all diagnostic tests as per standard protocols free of cost.3. Hospital shall provide 10 days post discharge free medicines to the patient within

package.4. Hospital shall provide reasonably good food to the patient, and shall make

alternate arrangement for food wherever in-house pantry is not available. The hospital shall not give money as an alternative to food.

5. Hospital shall pay return fare from Mandal Headquarters to the town where hospital is situated based on RTC fare.

6. Hospital use standard prosthetics and implants for surgical procedures and shall not charge extra cost from the patient on the ground of providing a better prosthetic, however if there is genuine technical reason to justify such a higher value prosthetic/implant it can request the technical committee to approve enhancement with evidence.

7. Hospital shall assist and facilitate the patient to procure compatible blood for the surgeries. The hospital shall provide blood from their own blood bank subject to availability within the package. In case of non-availability the hospital shall make efforts to procure from other blood banks, Red Cross, voluntary organizations etc. The hospital shall also issue a copy of the request letter to the patient.

PACKAGESSURGICAL PACKAGES

S.No. Code SYSTEM PACKAGES

S1 GENERAL SURGERY S1.1 HEAD & NECK S1.1.1 Neck 1 S1.1.1.1 Branchial Cyst Excision 200002 S1.1.1.2 Branchial Sinus Excision 200003 S1.1.1.3 Carotid Body-tumours Excision 300004 S1.1.1.4 Cystic Hygroma Excision-Extensive 200005 S1.1.1.5 Cystic Hygroma Excision-Major 20000

33

6 S1.1.1.6 Cystic Hygroma Excision-Minor 100007 S1.1.1.7 Excision of Lingual Thyroid 250008 S1.1.1.8 Parathyroidectomy 30000

9 S1.1.1.9Excision of Thyroglossal Cyst-

20000Fistula

10 S1.1.1.10 Cervical Rib excision 15000

11 S1.1.1.11Removal of Submandibular

10000Salivary gland

12 S1.1.1.12 Parotid Duct Repair 20000 S1.1.2 Mandible

13 S1.1.2.1 Hemimandibulectomy 2500014 S1.1.2.2 Segmental Mandible Excision 25000 S1.1.3 Tounge

15 S1.1.3.1 Partial glossectomy 15000 S1.1.4 Lip

16 S1.1.4.1 Abbe Operation 1500017 S1.1.4.2 Vermilionectomy 1500018 S1.1.4.3 Wedge Excision& Vermilionectomy 2000019 S1.1.4.4 Wedge Excision 15000 S1.1.5 Thyroid (Non-Malignant )

20 S1.1.5.1 Hemithyroidectomy 2000021 S1.1.5.2 Isthmectomy 2000022 S1.1.5.3 Partial Thyroidectomy 2000023 S1.1.5.4 Resection Enucleation 2000024 S1.1.5.5 Subtotal Thyroidectomy 2000025 S1.1.5.6 Total Thyroidectomy 20000 S1.2 BREAST

26 S1.2.1 Simple Mastectomy(NM) 25000 S1.3 ABDOMEN S1.3.1 Hernia

27 S1.3.1.1 Epigastric Hernia without Mesh 2000028 S1.3.1.2 Epigastric Hernia with Mesh 3000029 S1.3.1.3 Femoral Hernia 20000

30 S1.3.1.4Hiatus Hernia Repair

40000Abdominal

31 S1.3.1.5Rare Hernias (Spigalion,

20000obuturator, sciatic)

32 S1.3.1.6 Umbilical Hernia without mesh 2000033 S1.3.1.7 Umbilical Hernia with mesh 3000034 S1.3.1.8 Ventral and Scar Hernia without mesh 2000035 S1.3.1.9 Ventral and Scar Hernia with mesh 30000 S1.3.2 Appendix

36 S1.3.2.1 Lap. Appendicectomy 1800037 S1.3.2.2 Appendicular Perforation 20000

34

S1.3.3 Stomach, Duodenum and Jejunum

38 S1.3.3.1Highly Selective

25000Vagotomy

39 S1.3.3.2Selective Vagotomy

40000Drainage

40 S1.3.3.3 Vagotomy Pyloroplasty 40000

41 S1.3.3.4Gastrojejunostomy &

40000Vagotomy

42 S1.3.3.5Operation for

40000bleeding pepticUlcer

43 S1.3.3.6Partial/subtotal

40000Gastrectomy for ulcer

44 S1.3.3.7 Pyloromyotomy 2000045 S1.3.3.8 Gastrostomy 2000046 S1.3.3.9 Gastrostomy Closure 2000047 S1.3.3.10 Duodenal perforation 40000 S1.3.4 Small Intestine

48 S1.3.4.1 Intususception 40000

49 S1.3.4.2Operation for

40000Acute intestinal obstrucion

50 S1.3.4.3Operation for

40000Acute intestinal perforation

51 S1.3.4.4Operation for

40000Haemorrhage of thesmall intestine

52 S1.3.4.5Operations for Recurrent intestinal

40000obstruction (Noble plication other)

53 S1.3.4.6Resection & Anastomosis

35000of small intestine

54 S1.3.4.7 Ileostomy 2000055 S1.3.4.8 Ileostomy Closure 20000 S1.3.5 Large Intestine

56 S1.3.5.1Mal-rotation & Volvulus of the

40000Midgut

57 S1.3.5.2Operation for Volvulus

40000of large bowel

58 S1.3.5.3Operation of the Duplication of the

40000Intestines

59 S1.3.5.4Left Hemi-

30000Colectomy

60 S1.3.5.5Right Hemi

30000Colectomy

61 S1.3.5.6 Total Colectomy 40000

35

62 S1.3.5.7 Colostomy 2000063 S1.3.5.8 Colostomy Closure 20000 S1.3.6 Rectum and Anus

64 S1.3.6.1Pull through abdominal

30000Resection

65 S1.3.6.2 Anterior Resection 50000 S1.4 Liver

66 S1.4.1Operation for

30000Hydatid cyst ofLiver

67 S1.4.2 Portocaval Anastomosis 80000 S1.5 Gallbladder

68 S1.5.1 Cholecystectomy 2000069 S1.5.2 Lap. Cholecystectomy 3500070 S1.5.3 Cholecystectomy & Exploration CBD 3500071 S1.5.4 Cholecystoctomy 2500072 S1.5.5 Cystojejunostomy 4000073 S1.5.6 Cystogastrostomy 4000074 S1.5.7 Repair of CBD 40000 S1.6 Adrenals

75 S1.6.1Operation of Adernal

40000glands, bilateral for tumor

76 S1.6.2 Operation on Adrenal glands unilateral for tumour 25000 S1.7 Spleen

77 S1.7.1Splenectomy for

35000Hypersplenism

78 S1.7.2Splenorenal

60000Anastomosis

79 S1.7.3 Warren shunt 60000 S2 ENT SURGERY S2.1 EAR

80 S2.1.1 Labyrinthectomy 20,000

81 S2.1.2Facial Nerve

20,000Decompression

82 S2.1.3Temporal

50,000Bone Excision

S2.2 THROAT

83 S2.2.1Microlaryngeal

12,000Surgery

84 S2.2.2 Phono Surgery for Vocal cord paralysis 25,00085 S2.2.3 Laryngo Fissurectomy 20,00086 S2.2.4 Exision of Tumors in Pharynx 2000087 S2.2.5 Parapharyngeal 20000

36

Tumour Excision

88 S2.2.6 Adenoidectomy + Gromet insertion 1000089 S2.2.7 Uvulo-palato-Pharyngoplasty. 25000 S2.3 NOSE

90 S2.3.1 Endoscopic sinus surgery 1500091 S2.3.2 Mastoidectomy 1500092 S2.3.3 Tympanoplasty 1500093 S2.3.4 Stapedectomy + Veingraft 1500094 S2.3.5 Excision of Benign Tumour Nose 1500095 S2.3.6 Angiofibroma Nose 4000096 S2.3.7 Endoscopic DCR 20000

S2.4FOREIGN BODY REMOVAL (BRONCHUS/OESOPHAGUS)

97 S2.4.1 Bronchoscopy foreign body removal 20000 S3 OPTHALMOLOGY SURGERY S3.2 CORNEA and SCLERA

98 S3.2.1 THERAPEUTIC PENETRATING KERATOPLASTY 15000

99 S3.2.2 LAMELLAR KERATOPLASTY 3000100 S3.2.3 CORNEAL PATCH GRAFT 4000101 S3.2.4 SCLERAL PATCH GRAFT 6000102 S3.2.5 PENETRATING KERATOPLASTY 15000103 S3.2.6 DOUBLE Z-PLASTY 4000104 S3.2.7 AMNIOTIC MEMBRANE GRAFT 7000

S3.3 VITREO-RETINA S3.3.1 VITREA

105 S3.3.1.1 VITRECTOMY 6000

106 S3.3.1.2Vitrectomy + Membrane peeling+ Endolaser , silicon oil or gas

30000

107 S3.3.1.3 Vitrectomy + Membrane peeling+ Endolaser 25000108 S3.3.1.4 Vitrectomy + silicon oil or gas 20000109 S3.3.1.5 Removal of silicon oil or gas 6000

110 S3.3.1.6Monthly Intravitreal Anti-VEGF for macular degeneration / Per injection (maximum - 6)

7000

S3.3.2 RETINA 111 S3.3.2.1 Scleral buckle for Retinal detachment 15000

112 S3.3.2.2Photocoagulation for Diabetic Retinopathy /per sitting

1500

S3.4 ORBIT 113 S3.4.1 SOCKET RECONSTRUCTION 7000114 S3.4.2 DERMIS FAT GRAFT 9000115 S3.4.3 ORBITOTOMY 10000116 S3.4.4 Enucleation with orbital Implant 20000

S3.5 SQUINT CORRECTION SURGERY 37

117 S3.5.1 RECTUS MUSCLE SURGERY(SINGLE) 6000118 S3.5.2 RECTUS MUSCLE SURGERY(TWO/THREE) 12000119 S3.5.3 OBLIQUE MUSCLE 6000

S3.6 LID SURGERY 120 S3.6.1 Lid reconstruction Surgery- 15000

S3.7 PEDIATRIC OPHTHALMIC SURGERY 121 S3.3.6 Photocoagulation for Retinopathy of pre-maturity 7500

122 S3.3.7Paediatric Cataract Surgery (Phacoemulsification + IOL)

15000

123 S3.3.8 Glaucoma filtering Surgery for Paediatric Glaucoma 15000

S4 GYNAECOLOGY AND OBSTETRICS SURGERY

S4.1 Obstetrics 124 S4.1.1 Caesarean Hysterectomy with Bladder Repair 30,000

125 S4.1.2Rupture Uterus with

25,000Tubectomy

126 S4.1.3Eclampsia with Complications requiring ventilatory support

20000

127 S4.1.4 Abruptio-placenta with Coagulation Defects(DIC) 20000 S4.2 Gynaecology

128 S4.2.1 LAVH 20,000129 S4.2.2 Laparoscopic Cystectomy 20,000130 S4.2.3 Laparoscopic Ectopic Resection 20,000131 S4.2.5 Laparoscopic Myomectomy 25,000132 S4.2.6 Laparoscopic recanalisation 20,000133 S4.2.7 Laparoscopic Sling operations 25,000134 S4.2.8 Laparoscopic adhesolysis 25,000135 S4.2.9 Vaginal Hysterectomy 20,000

136 S4.2.10Vaginal Hysterectomy with

30,000pelvic floor repair

137 S4.2.12Cystocele, Rectocele &

20,000Perineorraphy

138 S4.2.14Mc Indo's repair for

30,000Vaginal Atresia

139 S4.2.16 Vault prolapse abdominal repair 30,000140 S4.2.17 Vault prolapse abdominal repair with mesh 40,000

S5.3 Amputations (Non-Traumatic) 141 S5.3.1 Amputations - Forequarter 30,000142 S5.3.2 Amputations - Hind Quarter and Hemipelvectomy 40,000

S5.4Bone and Joint Surgery & Osteotomy Procedures including post-polio and cerebral palsy corrections

143 S5.4.1 Arthrodesis of - Major Joints 30,000144 S5.4.2 Arthroscopy - Diagnostic 20,000

38

145 S5.4.3 Arthroscopy - Operative Meniscectomy 25,000146 S5.4.4 Arthroscopy - ACL Repair 30,000

147 S5.4.5Avascular Necrosis of Femoral Head (core decompression)

15,000

148 S5.4.6Soft Tissue Reconstructive Procedures for Joints / osteotomies

Up to 30,000

S5.5 Spine Surgery 149 S5.5.1 Anterolateral Clearance for Tuberculosis 50,000150 S5.5.2 Costo Transversectomy 30,000151 S5.5.3 Spinal Ostectomy and Internal Fixations 40,000

S5.6 Soft Tissue Surgery 152 S5.6.1 Nerve Repair with Grafting 30,000153 S5.6.2 Neurolysis / Nerve Suture 25,000154 S5.6.3 Operations for Brachial Plexus & Cervical Rib 30,000

S5.7 TUMOR SURGERY

155 S5.7.1Excision of Bone Tumours - Deep with re-construction with conventional prosthesis

40,000

S6 SURGICAL GASTROENTEROLOGY S6.1 Emergency

156 S6.1.1 Surgery for Bleeding Ulcers 40000157 S6.1.2 Surgery for Obscure GI Bleed 60000

S6.2 Oesophagus 158 S6.2.1 Colonic Pull up 30000159 S6.2.2 Oesophagectomy 60000160 S6.2.3 Oesophago-Gastrectomy 75000161 S6.2.4 Lap Heller's myotomy 30000162 S6.2.5 Lap Fundoplications 45000

S6.3 Stomach 163 S6.3.1 Partial Gastrectomy 40000164 S6.3.2 Total Gastrectomy 40000165 S6.3.3 Truncal vagotomy + Gastro Jejunostomy 40000166 S6.3.4 Distal Gastrectomy for Gastric Outlet obstruction 40000167 S6.3.5 Surgery for Corrosive injury Stomach 50000

S6.4 Small Intestine 168 S6.4.1 Volvulus 40000169 S6.4.2 Malrotation 40000170 S6.4.3 Lap Adhesiolysis 40000

S6.5 Large Intestine 171 S6.5.1 Right Hemicolectomy 30000172 S6.5.2 Left Hemicolectomy 30000173 S6.5.3 Extended Right Hemicolectomy 35000174 S6.5.4 Anterior Resection 40000175 S6.5.5 Anterior Resection with Ileostomy 50000176 S6.5.6 Abdomino Perineal Resection(Non-Malignant) 50000

39

177 S6.5.7 Hartman's Procedure with Colostomy 45000 S6.5.8 Ulcerative Colitis S6.5.8.1 III Stage Procedure

178 S6.5.8.1.1 I Stage-Sub Total Colectomy + Ileostomy 50000179 S6.5.8.1.2 II Stage-J - Pouch 30000180 S6.5.8.1.3 III Stage-Ileostomy Closure 20000181 S6.5.8.2 II Stage Procedure

182 S6.5.8.2.1I Stage- Sub Total Colectomy + Ileostomy + J - Pouch

80000

183 S6.5.8.2.2 II Stage- Ileostomy Closure 20000 S6.6 Liver:

184 S6.6.1Hepato Cellular Carcinoma(Advanced) Radio Frequency Ablation

60000

185 S6.6.2Haemangioma SOL Liver Hepatectomy + Wedge Resection

75000

186 S6.6.3 Hydatid cyst-Marsupilisation 30000 Gall Bladder S6.7 Gall Bladder

187 S6.7.1 Cyst excision + Hepatic Jejunostomy 45000188 S6.7.2 Cholecystectomy 15000189 S6.7.3 GB+ Calculi CBD Stones or Dilated CBD 25000190 S6.7.4 Lap. Cholecystectomy 30000191 S6.7.5 Hepatico Jejunostomy 45000

192 S6.7.6Choledochoduodenostomy Or Choledocho jejunostomy

35000

S6.8 Spleen 193 S6.8.1 Splenectomy 35000

194 S6.8.2Splenectomy + Devascularisation + Spleno Renal Shunt

60000

195 S6.8.3 Spleenectomy for Space occupying lesion 35000 S6.9 Pancreas

196 S6.9.1 Lap- Pancreatic Necrosectomy 100000197 S6.9.2 Lateral PancreaticoJejunostomy (Non- Malignant) 100000198 S6.9.3 Pancreatic Necrosectomy (open) 100000199 S6.9.4 Distal Pancreatectomy + Splenectomy 100000200 S6.9.5 Central Pancreatectomy 100000

S6.9.6 Pseudo cyst 201 S6.9.7 Cysto Jejunostomy 40000202 S6.9.8 Cysto Gastrostomy 40000

S6.10 Hernia 203 S6.10.1 Diaphragmatic Hernia (Gortex Mesh Repair) 40000

CARDIOTHORACIC SURGERIES AND PROCEDURES AAROGYASRI-II

S7.4 CHEST SURGERY

40

204 S7.4.1 Diaphragmatic Eventeration 40000205 S7.4.2 DIAPHRAGMATIC HERNIA 40000

206 S7.4.3OESOPHAGEAL DIVERTICULA /ACHALASIA CARDIA

40000

S7.5 DIAPHRAGMATIC INJURIES

207 S7.5.1THORACOTOMY, THORACO ABDOMINAL APPROACH

40000

S7.6 BRONCHIAL INJURIES/FB 208 S7.6.1 FOREIGN BODY REMOVAL WITH SCOPE 20000

S7.6.2REPAIR SURGERY FOR INJURIES DUE TO FB

40000

S7.8 OESOPHAGEAL INJURY/FB

209 S7.8.1

GASTRO STUDY FOLLOWED BY THORACOTOMY & REPAIRS for OESOPHAGEAL INJURY for Corrosive Injuries/FB

50000

S7.9 VASCULAR INJURY

210 S7.9.1SURGERY WITHOUT GRAFT for ARTERIAL INJURIES VENOUS INJURIES

10000

211 S7.9.2 SURGERY WITH VEIN GRAFT 15000212 S7.9.3 WITH PROSTHETIC GRAFT 40000

213 S7.9.1Vascular Injury in upper limbs - Axillary, brachial, radial and ulnar - Repair with Vein Graft

Up to 40000

214 S7.9.2 Major Vascular Injury - in lower limbs - Repair Up to 60000

215 S7.9.3Minor Vascular Injury Repair - Tibial vessels in leg

Up to 20000

216 S7.9.4 Minor Vascular Injury Repair - vessels in Foot Up to 20001

217 S7.9.5 Neck Vascular Injury - Carotid Vessels Up to 100000

218 S7.9.6Abdominal Vascular Injuries - Aorta, Illac arteries, IVC, iliac Veins

Up to 100000

219 S7.9.7 Thoracic Vascular Injuries Up to 150000

S7.10 CARDIAC INJURES 220 S7.10.1 SURGERY WITHOUT CPB 40000221 S7.10.2 SURGERY WITH CPB 75000

S7.11 VASCULAR SURGERIES 222 S7.11.1 Peripheral Embolectomy without graft 25000

223 S7.11.2Aorto Billiac / Bifemoral bypass with Synthetic Graft

125000

224 S7.11.3 Axillo bifemoral bypass with Synthetic Graft 100000225 S7.11.4 Femoro Distal Bypass with Vein Graft 60000226 S7.11.5 Femoro Distal Bypass with Synthetic Graft 80000

227 S7.11.6Axillo Brachial Bypass using with Synthetic Graft

65000

41

228 S7.11.7 Brachio - Radial Bypass with Synthetic Graft 50000

229 S7.11.8Excision of Carotid body Tumor with vascular repair

60000

230 S7.11.9 Carotid artery bypass with Synthetic Graft 100000231 S7.11.10 Excision of Arterio Venous malformation - Large 75000232 S7.11.11 Excision of Arterio Venous malformation - Small 40000233 S7.11.12 Arterial Embolectomy 20000234 S7.11.13 A V Fistula at wrist 10000235 S7.11.14 A. V Fistula at Elbow 20000236 S7.11.15 D V T - IVC Filter 100000237 S7.11.16 Vascular Tumors 40000238 S7.11.17 Small Arterial Aneurysms - Repair 15000239 S7.11.18 Medium size arterial aneurysms - Repair 50000

240 S7.11.19Medium size arterial aneurysms with synthetic graft

75000

PEDIATRIC SURGERIES S8.5 Congenital Malformations

241 S8.5.1 Hamartoma Excision 20000242 S8.5.2 Hemangioma Excision 25000243 S8.5.3 Lymphangioma Excision 40000

S8.6 HEAD AND NECK 244 S8.6.1 Neuroblastoma 25000245 S8.6.2 Congenital Dermal Sinus 30000246 S8.6.3 Cystic Lesions of the Neck 20000247 S8.6.4 Encephalocele 20000248 S8.6.5 Sinuses & Fistula of the Neck 20000

S8.7 CHEST 249 S8.7.1 Bronchoscopy foreign body removal 20000

250 S8.7.2Paediatric Esophageal obstructions-Surgical correction

30000

251 S8.7.3 Paediatric Esophageal Substitutions 60000252 S8.7.4 Thoracoscopic cysts excision 40000253 S8.7.5 Thoracoscopic decortication 40000254 S8.7.6 Thoracic Duplications 40000255 S8.7.7 Thoracic Wall defects- Correction 50000

S8.8 ABDOMEN 256 S8.8.1 Gastric outlet obstructions 30000257 S8.8.2 Gastro Esophageal Reflux Correction 30000258 S8.8.3 Hydatid cysts in Paediatric patient 40000259 S8.8.4 Intestinal Polyposis Surgical correction 50000260 S8.8.5 Intususception 40000261 S8.8.6 Paediatric Acute Intestinal Obstruction 40000262 S8.8.7 Laparoscopic Appendicectomy 25000263 S8.8.8 Laparoscopic Choleycystectomy 40000

42

264 S8.8.9Laparoscopic pull through for Ano Rectal Anomalies

60000

265 S8.8.10 Laparoscopic pull through surgeries for HD 60000266 S8.8.11 Paediatric Splenectomy (Non Traumatic) 35000267 S8.8.12 Surgeries on adrenal gland in Children 25000

S8.9 GENITOURINARY SYSTEM 268 S8.9.1 Nephrectomy 40000269 S8.9.2 Epispadiasis - Correction 40000270 S8.9.3 Scrotal transposition repair 20000271 S8.9.4 Undescended Testis 25000272 S8.9.5 Torsion Testis 25000273 S8.9.6 Laparoscopic Orchidopexy 25000274 S8.9.7 Laparoscopic Varicocele ligation 25000

GENITOURINARY SURGERIES AAROGYASRI-II

S9.5 Renal Transplantation

275 S9.5.1Post Transplant immunosuppressive Treatment from 7th to 12 th Month after transplantation

50000

S9.6 RENAL 276 S9.6.1 Nephrostomy 10000277 S9.6.2 Nephrectomy Pyonephrosis/XGP 40000278 S9.6.3 Simple Nephrectomy 40000279 S9.6.4 Lap. Nephrectomy Simple 30000280 S9.6.5 Lap. Nephrectomy Radical 40000281 S9.6.6 Lap. Partial Nephrectomy 35000

282 S9.6.7Bilateral

25000Nephroureterectomy

283 S9.6.8 Renal Cyst Excision 15000 S9.7 RENAL STONE SURGERY/THERAPIES

284 S9.7.1 Endoscope Removal of stone in Bladder 10000

285 S9.2.5Anatrophic Peylolithotomy for Staghorn Caliculus

50000

S9.8 CORRECTIVE SURGERIES 286 S9.8.1 Anderson Hynes Pyeloplasty 40000287 S9.8.2 Vasico Vaginal Fistula 40000288 S9.8.3 Epispadiasis - Correction 40000289 S9.8.4 Closure of Urethral Fistula 25000290 S9.8.5 Optical Urethrotomy 20000291 S9.8.6 Perineal Urethrostomy 20000292 S9.8.7 Ureteric Reimplantation 25000293 S9.8.8 Ileal Conduit formation 20000294 S9.8.9 Ureterocele 15000

S9.9 BLADDER and PROSTATE 295 S9.9.1 Transurethral resection of prostate (TURP) 30000296 S9.9.2 TURP Cyst lithotripsy 30000

43

297 S9.9.3 Open prostatectomy 30000298 S9.9.4 Caecocystoplasty 30000299 S9.9.5 Total cystectomy 35000300 S9.9.6 Diverticulectomy 10000

301 S9.9.7Incontinence Urine

20000(Female)

302 S9.9.8Incontinence Urine

20000(male)

S9.10 TESTIS AND PENIS 303 S9.10.1 Orchidopexy Bilateral 15000304 S9.10.2 Torsion testis 12000305 S9.10.3 Chordee correction 15000

306 S9.10.4Partial amputation of

15000Penis(Non-Malignant)

307 S9.10.5Total amputation of

25000Penis(Non-Malignant)

NEUROSURGERY S10.4 BRAIN

308 S10.4.1 Endoscopy procedures 65,000309 S10.4.1.1 Endoscopic Third Ventriclostomy(ETV) 30,000310 S10.4.2 Intra-Cerebral Hematoma evacuation 60,000311 S10.4.3 Decompressive Craniectomy 50,000312 S10.5.5 Syringomyelia 65,000

S10.6 SOFT TISSUE and VASCULAR SURGERIES 313 S10.6.1 Repair of Brachial plexus injury 60,000314 S10.6.2 Cervical Sympathectomy 50,000315 S10.6.3 Lumbar sympathectomy 50,000316 S10.6.4 Decompression/Excision of Optic nerve lesions 65,000317 S10.6.5 Peripheral nerve injury repair 50,000318 S10.6.6 Proptosis 60,000

S10.7 EPILEPSY Surgery 319 S10.7.1 Temporal Lobectomy 90 000320 S10.7.2 Lesionectomy type 1 1 50 000321 S10.7.3 Lesionectomy type 2 160 000322 S10.7.4 Temporal lobectomy plus Depth Electrodes 140 000

S10.8 MANAGEMENT OF TRIGEMINAL NEURALGIA

323 S10.8.1Radiofrequency ablation for Trigeminal Neuralgia

30000

324 S10.8.2Microvascular decompression for Trigeminal Neuralgia

60000

S10.9 MANAGEMENT OF ANEYRISMS 325 S10.9.1 Embolization of Aneurysm 50000326 S10.9.2 Cost of each coil 30000

SURGICAL ONCOLOGY AAROGYASRI-II

44

S11.9 Ca.Oral cavity 327 S11.9.1 MarginalMandibulectomy 25,000328 S11.9.2 Segmental Mandibulectomy 25,000329 S11.9.3 Total glossectomy + Reconstruction 40,000

330 S11.9.4Full thickness Buccal mucosal resection & Reconstruction

50,000

S11.10 Ca.Eye/ Maxilla /Para Nasal Sinus 331 S11.10.1 Orbital exenteration 25,000332 S11.10.2 Maxillectomy + Orbital exenteration 35,000333 S11.10.3 Maxillectomy + Infratemporal Fossa clearance 40,000334 S11.10.4 Cranio Facial Resection 70,000

S11.11 Ca. Nasopharynx 335 S11.11.1 Resection of Nasopharyngeal Tumor 50,000

S11.12 Ca.Soft Palate 336 S11.12.1 Palatectomy Any type 30,000

S11.13 Ca. Ear 337 S11.13.1 Sleeve Resection 25,000338 S11.13.2 Lateral Temporal bone resection 30,000339 S11.13.3 Subtotal Temporal bone resection 50,000340 S11.13.4 Total Temporal bone resection 60,000

S11.14 Ca. Salivary Gland 341 S11.14.1 Submandibular Gland Excision 20,000

S11.15 Ca. Thyroid 342 S11.15.1 Tracheal Resection 52,000343 S11.16 Ca. Trachea 344 S11.16.1 Sternotomy + Superior Mediastinal Dissection 45,000345 S11.16.2 Tracheal Resection 40,000

S11.17 Ca. Parathyroid 346 S11.17.1 Parathyroidectomy 30,000

S11.18 Ca. Gastro Intestinal Tract 347 S11.18.1 Small bowel resection 40,000348 S11.18.2 Closure of Ileostomy 20,000349 S11.18.3 Closure of Colostomy 20,000

S11.19 Ca.Rectum

350 S11.19.1Abdomino Perineal Resection (APR) + Sacrectomy

50,000

351 S11.19.2 Posterior Exenteration 50,000352 S11.19.3 Total Exenteration 75,000353 S11.20 Ca. Gall Bladder 354 S11.20.1 Radical Cholecystectomy 60,000

S11.21 Spleen 355 S11.21.1 Splenectomy 35,000

S11.22 Retroperitoneal Tumor 356 S11.22.1 Resection of Retroperitoneal Tumors 45,000

45

S11.23 Abdominal wall tumor 357 S11.23.1 Abdominal wall tumor Resection 35,000358 S11.23.2 Resection with reconstruction 45,000

S11.24 Gynaec Cancers 359 S11.24.1 Bilateral pelvic lymph Node Dissection(BPLND) 25,000360 S11.24.2 Radical Trachelectomy 40,000361 S11.24.3 Radical vaginectomy 40,000362 S11.24.4 Radical vaginectomy + Reconstruction 45,000

S11.25 Ca. Cervix

363 S11.25.1Radical Hysterectomy +Bilateral Pelvic Lymph Node Dissection (BPLND) + Bilateral Salpingo Ophorectomy (BSO) / Ovarian transposition

45,000

364 S11.25.2 Anterior Exenteration 60,000365 S11.25.3 Posterior Exenteration 50,000366 S11.25.4 Total Pelvic Exenteration 75,000367 S11.25.5 Supra Levator Exenteration 70,000

S11.26 Ca. Endometrium

368 S11.26.1

Total Abdominal Hysterectomy(TAH)+Bilateral Salpingo ophorectomy (BSO)+Bilateral pelvic lymph Node Dissection (BPLND)+ Omentectomy

35,000

S11.27 Soft tissue /Bone tumors - Chest wall 369 S11.27.1 Chest wall resection 20,000370 S11.27.2 Chest wall resection + Reconstruction 30,000

S11.28 Bone / Soft tissue tumors S11.28.1 Limb salvage surgery

371S11.28.1.1

-Without prosthesis 40,000

372S11.28.1.2

-With Custom made Prosthesis 50,000

373S11.28.1.3

-With Modular Prosthesis 75,000

374 S11.28.2 Forequarter amputation 40,000375 S11.28.3 Hemipelvectomy 55,000376 S11.28.4 Internal hemipelvectomy 65,000377 S11.28.5 Curettage & bone cement 30,000378 S11.28.6 Bone resection 30,000379 S11.28.7 Shoulder girdle resection 40,000380 S11.28.8 Sacral resection 60,000

S11.29 Genito urinary Cancer 381 S11.29.1 Partial Nephrectomy 55,000

382 S11.29.2Nephroureterectomy for Transitional Cell Carcinoma of renal pelvis

50,000

S11.30 Testes cancer

383 S11.30.1Retro Peritoneal Lymph Node Dissection(RPLND) (for Residual Disease)

60,000

46

384 S11.30.2 Adrenalectomy 45,000385 S11.30.3 Urinary diversion 40,000

386 S11.30.4Retro Peritoneal Lymph Node Dissection RPLND as part of staging

20,000

S11.31 Ca. Urinary Bladder 387 S11.31.1 Anterior Exenteration 60,000388 S11.31.2 Total Exenteration 75,000389 S11.31.3 Bilateral pelvic lymph Node Dissection(BPLND) 20,000

S11.32 Thoracic and Mediastinum 390 S11.32.1 Mediastinal tumor resection 50,000

S11.33 Lung 391 S11.33.1 Lung metastatectomy - solitary 50,000392 S11.33.2 Lung metastatectomy - Multiple 60,000393 S11.33.3 Sleeve resection of Lung cancer. 90,000

S11.34 Esophagus

394 S11.34.1Oesophagectomy with Two field Lymphadenectomy

90,000

395 S11.34.2Oesophagectomy with Three field Lymphadenectomy

1,00,000

S11.35 Palliative Surgeries 396 S11.35.1 Tracheostomy 5,000397 S11.35.2 Gastrostomy 20,000398 S11.35.3 Jejunostomy 20,000399 S11.35.4 Ileostomy 20,000400 S11.35.5 Colostomy 20,000401 S11.35.6 Suprapubic Cystostomy 10,000402 S11.35.7 Intercostal Drainage(ICD) 3,000403 S11.35.8 Gastro Jejunostomy 35,000404 S11.35.9 Ileotransverse Colostomy 50,000405 S11.35.10 Substernal bypass 35,000

S11.36 Reconstruction 406 S11.36.1 Myocutaneous / cutaneous flap 25,000407 S11.36.2 Micro vascular reconstruction 45,000

MEDICAL ONCOLOGY AAROGYASRI-II

S12.30 Colo Rectal Cancer Stage 2 and 3

408 S12.30.1XELOX along with Adjuvant chemotherapy of AS-I

4000

S12.31 MULTIPLE MYELOMA

409 S12.31.1Zoledronic acid along with Adjuvant Chemotherapy of AS-I

3000

S12.32 FEBRILE NEUTROPENIA FN - High risk 1

47

410 S12.32.11ST Line iv antibiotics And other supportive therapy ( third generation cephalosporin, aminoglycoside etc.,)

9000

FN - High risk 2

411 S12.32.2

2nd line iv antibiotics and other supportive therapy(Carbapenems, Fourth generation cephalosporins, Piperacillin, anti-fungal - azoles etc.,)

30000

RADIATION ONCOLOGY AAROGYASRI-II

S13.4 SPECIALIZED RADIATION THERAPY S13.4.1 IMRT (Intensity modulated radiotherapy)

412 S13.4.1.1 Upto 40 fractions in 8 weeks 100000 S13.4.2 3DCRT(3-D conformational radiotherapy)

413 S13.4.2.1 Upto 30 fractions in 6 weeks 75000 S13.4.3 SRS/SRT

414 S13.4.3.1 Upto 30 fractions in 6 weeks 75000 S14 PLASTIC SURGERY

415 S14.4Corrective Surgery for Congenital deformity of hand (per hand)

15,000

416 S14.5 Corrective Surgery for Craniosynostosis 50,000417 S14.6 Cup and Bat ears 20,000

418 S14.7Flapcover for Electrical burns with vitals exposed

50,000

419 S14.8 Reduction surgery for Filarial lymphoedema 20,000420 S14.9 Hemifacial atrophy 30,000421 S14.10 Hemifacial Microsmia 50,000422 S14.11 Leprosy reconstructive surgeroy 20,000423 S14.12 Nerve and tendon repair + Vascular repair 30,000424 S14.13 Ptosis 25,000425 S14.14 Tumour of mandible and maxilla 40,000426 S14.15 Vaginal atresia 25,000427 S14.16 Vascular malformations 25,000

MEDICAL PACKAGESS.No. Code Disease Package

M1 CRITICAL CARE 1 M1.1 Acute severe asthma 45,000 with Acute respiratory failure

2 M1.2COPD Respiratory Failure (infective exacerbation)

70 000

3 M1.3Acute Bronchitis and Pneumonia with Respiratory failure

50000

4 M1.4 ARDS 800005 M1.5 ARDS with Multi Organ failure 100000

48

6 M1.6 ARDS plus DIC (Blood & Blood products) 1200007 M1.7 Poison ingestion requiring 30,000 Ventilatory assistance 8 M1.8 Septic Shock(ICU Management) 50000 M2 GENERAL MEDICINE 9 M2.1 Thrombocytopenia with bleeding diathesis 50,00010 M2.2 Hemophilia 50,00011 M2.3 Other Coagulation disorders 50,00012 M2.3 Chelation Therapy for Thalassemia Major 2000013 M2.4 Cerebral Malaria 2000014 M2.5 TB meningitis 3000015 M2.6 Snake bite requiring ventilator support 5000016 M2.7 Scorpion Sting requiring ventilator support 2500017 M2.8 Metabolic Coma requiring Ventilatory Support 30000 M3 INFECTIOUS DISEASES

18 M3.1 Tetanus severe 2000019 M3.2 Diphtheria Complicated 2500020 M3.3 Cryptococcal Meningitis 20,000 M4 PEDIATRICS M4.1 NEONATAL INTENSIVE CARE

21 M4.1.1Term baby with culture positive sepsis- Non ventilated Hyperbilirubinemia

25000

22 M4.1.233 to 34 weeks preterm baby Severe Hyaline membrane disease Clinical sepsis Bubble CPAP Hyperbilirubinemia

40000

23 M4.1.333 to 34 weeks preterm baby Severe Hyaline membrane disease Clinical sepsis Mechanical ventilation Hyperbilirubinemia

60000

24 M4.1.435 to 36 weeks Preterm Mild Hyaline membrane disease Culture positive sepsis Nonventilated Hyperbilirubinemia

35000

25 M4.1.533 to 34 weeks preterm Mild Hyaline membrane disease Culture positive sepsis - Nonventilated Hyperbilirubinemia

45000

26 M4.1.6

33 to 34 weeks preterm Severe Hyaline membrane disease Culture positive sepsis Mechanical ventilation/ Bubble CPAP Hyperbilirubinemia

60000

27 M4.1.7

30 to 32 weeks preterm Severe Hyaline membrane disease Clinical/ Culture positive sepsis Mechanical ventilation Hyperbilirubinemia

90000

28 M4.1.8<30 weeks preterm Severe Hyaline membrane disease Clinical/ Culture positive sepsis Mechanical ventilation Hyperbilirubinemia

90000

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29 M4.1.9

33 to 34 weeks preterm Severe Hyaline membrane disease Clinical/Culture positive sepsis Patent ductus arteriosus- Medical management Mechanical ventilation Hyperbilirubinemia

70000

30 M4.1.10

30 to 32 weeks preterm Severe Hyaline membrane disease Clinical/Culture positive sepsis Patent ductus arteriosus - Medical management Mechanical ventilation Hyperbilirubinemia

90000

31 M4.1.11

<30 weeks preterm Severe Hyaline membrane disease Clinical/Culture positive sepsis Patent ductus arteriosus - Medical management Mechanical ventilation Hyperbilirubinemia

90000

32 M4.1.12Term baby with persistent pulmonary hypertension Ventilation-HFO Hyperbilirubinemia Clinical sepsis

80000

33 M4.1.13Term baby with severe perinatal asphyxia - Non ventilated Clinical sepsis Hyperbilirubinemia

25000

34 M4.1.14Term baby with severe perinatal asphyxia - Ventilated Clinical sepsis Hyperbilirubinemia

40000

35 M4.1.15Term baby Severe hyperbilirubinemia Clinical sepsis

25000

36 M4.1.16 Term baby with seizures ventilated 25000

37 M4.1.17Necrotising enterocolitis, Clinical sepsis Non ventilated Hyperbilirubinemia

25000

38 M4.1.18Term baby, fulminant culture positive sepsis, septic shock, Ventilated, Hyperbilirubinemia Renal failure

40000

M4.2 PEDIATRIC INTENSIVE CARE M4.2.1 RESPIRATORY

39 M4.2.1.1 Severe Bronchiolitis 15000 (Non Ventilated)

40 M4.2.1.2 Severe Bronchiolitis 20000 ( Ventilated)

41 M4.2.1.3 Severe Bronchopneumonia 15000 (non Ventilated)

42 M4.2.1.4 Severe Bronchopneumonia 30000 ( Ventilated)

43 M4.2.1.5 Acute Severe Asthma 35000 (Ventilated)

44 M4.2.1.6 Severe Aspiration Pneumonia 20000 (Non Ventilated)

45 M4.2.1.7 Severe Aspiration Pneumonia 25000 ( Ventilated)

46 M4.2.1.8 ARDS with Multi-organ failure 100000

50

47 M4.2.1.9 ARDS plus DIC (Blood & Blood products) 120000 M4.2.2 CARDIOVASCULAR

48 M4.2.2.1 Severe Myocarditis 4000049 M4.2.2.2 Congenital heart disease with infection 30000 (non Ventilated)

50 M4.2.2.3Congenital heart disease with infection and cardiogenic shock

50000

(Ventilated) 51 M4.2.2.4 Cardiogenic shock 5000052 M4.2.2.5 Infective Endocarditis 50000 M4.2.3 Central Nervous System

53 M4.2.3.1 Meningo- encephalitis 40000 (Non Ventilated)

54 M4.2.3.2 Meningo- encephalitis 60000 ( Ventilated)

55 M4.2.3.3 Status Epilepticus 5000056 M4.2.3.4 Febrile Seizures 25000 (atypical- mechanical ventilated)

57 M4.2.3.5 Intra cranial bleed 40000 M4.2.4 Gastro intestinal system

58 M4.2.4.1 Acute Gastro intestinal bleed 3000059 M4.2.4.2 Acute Pancreatitis 5000060 M4.2.4.3 Acute hepatitis with hepatic encephalopathy 50000 M4.2.5 Renal

61 M4.2.5.1 Acute renal Failure 40000 M4.2.6 Endocrine

62 M4.2.6.1 Diabetes Ketoacidosis 30000 M4.2.7 Infection

63 M4.2.7.1 Septic shock 50000 M4.2.8 Toxicology

64 M4.2.8.1 Snake bite requiring ventilatory assistance 50000

65 M4.2.8.2Scorpion sting with myocarditis and cardiogenic shock requiring ventilatory Assistance

25000

66 M4.2.8.3Poison ingestion/ aspiration requiring ventilatory assistance

40000

M4.3 GENERAL PEDIATRICS RESPIRATORY

67 M4.3.1Acute Broncho/ lobarpneumonia with empyema/ pleural effusion

20000

68 M4.3.2Acute Broncho/lobarpneumonia with pyo pneumothorax

20000

M4.4 CARDIOVASCULAR

69 M4.4.1Congenital heart disease with congestive cardiac failure

15000

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70 M4.4.2Acquired heart disease with congestive cardiac failure

15000

71 M4.4.3 Viral Myocarditis 15000 M4.5 RENAL

72 M4.5.1 Steroid Resistant Nephrotic syndrome 25000 Complicated or Resistant

73 M4.5.2Urinary tract infection with complications like pyelonephritis and renal failure

15000

74 M4.5.3 Acute Renal Failure 1000075 M4.5.4 Acute Renal Failure with dialysis 20000 M4.6 SEVERE ANEMIAS

76 M4.6.1 Thalassemia Major requiring chelation Therapy 20,00077 M4.6.2 Haemophillia including Von Willibrands 20,00078 M4.6.3 Anemia of unknown cause 10000 M4.7 INFECTIONS

79 M4.7.1 Pyogenic meningitis 3500080 M4.7.2 Neuro tuberculosis 1000081 M4.7.3 Neuro tuberculosis with ventilation 2000082 M4.7.4 Enteric Fever 10000 Complicated

83 M4.7.5 Cerebral Malaria (Falciparum) 10000 M4.8 NEUROLOGY

84 M4.8.1 Convulsive Disorders/Status Epilepticus (Fits) 1000085 M4.8.2 Stroke Syndrome 2000086 M4.8.3 Encephalitis / Encephalopathy 1500087 M4.8.4 Guillian-Barre Syndrome 6000088 M5.2 Infective Endocarditis 25,00089 M5.3 Pulmonary, Embolism 30,00090 M5.4 Complex Arrhythmias 95,00091 M5.5 Simple Arrythmias 70,00092 M5.6 Pericardial Effusion, Tamponade 25,000 M6 NEPHROLOGY

93 M6.1 Acute Renal Failure-(ARF) 20,00094 M6.2 Nephrotic Syndrome 15,00095 M6.3 Rapidly progressive Renal Failure (RPRF) 35,00096 M6.4 Chronic Renal Failure 1 (CRF ) 15,00097 M6.5 Maintenance Haemodialysis for CRF 10000/month M7 NEUROLOGY

98 M7.1 ADEM or Relapse in Multiple sclerosis 20,00099 M7.2 CIDP 8,000

100 M7.3 Hemorrhagic Stroke/Strokes 25,000101 M7.4 Ischemic Strokes 20,000102 M7.5 Myopathies - Acquired 15,000103 M7.6 NEUROINFECTIONS -Fungal Meningitis 40,000104 M7.7 NEUROINFECTIONS -Pyogenic Meningitis 25,000

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105 M7.8NEUROINFECTIONS -Viral Meningoencephalitis ( Including Herpes encephalitis)

25,000

106 M7.9 Neuromuscular (myasthenia gravis) 15,000107 M7.10 Neuropathies (GBS) 35,000108 M7.11 Optic neuritis 10000109 M7.12 Immunoglobulin Therapy - IV 100000

M8 PULMONOLOGY

110 M8.1Bronchiectasis with repeated hospitalisation>6per year

20000

111 M8.2 Lung Abscess ,non resolving 15000112 M8.3 Pneumothorax ( Large/Recurrent) 35000113 M8.4 Interstitial Lung diseases 30000114 M8.5 Pneumoconiosis 25000115 M8.6 Acute Respiratory Failure ( without ventilator) 25000116 M8.7 Acute Respiratory Failure ( with ventilator) 50000

M9 DERMATOLOGY 117 M9.1 Pemphigus / 25,000

Pemphigoid 118 M9.2 Toxic epidermal necrolysis 30,000119 M9.3 Stevens- Johnson Syndrome 20,000

M10 RHEUMATOLOGY 120 M10.1.1 SLE (SYSTEMIC LUPUS ERYTHEMATOSIS) 15,000121 M10.1.2 SLE with Sepsis 50000122 M10.2 SCLERODERMA 15,000

123 M10.3MCTD MIXED CONNECTIVE TISSUE DISORDER

15,000

124 M10.4 PRIMARY SJOGREN'S SYNDROME 15,000125 M10.5 VASCULITIS 10,000

M11 ENDOCRINOLOGY

M11.1Uncontrolled Diabetes mellitus with infectious emergencies

126 M11.1.1 Pyelonephritis 20,000127 M11.1.2 Lower Respiratoy tract infection 20,000128 M11.1.3 Fungal sinusitis 40,000129 M11.1.4 Cholecystitis 25,000130 M11.1.5 Cavernous sinus thrombosis 40,000131 M11.1.6 Rhinocerebral mucormycosis 40,000

M11.2 OTHER ENDOCRINAL DISORDERS 132 M11.2.1 Hypopitutarism 1,00,000133 M11.2.2 Pituitary - Acromegaly 15000134 M11.2.3 CUSHINGs Syndrome 30,000135 M11.2.4 Delayed Puberty Hypogonadism 12,000

(ex.Turners synd, Kleinfelter synd) M12 GASTROENTEROLOGY

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136 M12.1 Corrosive Oesophageal injury 20000137 M12.2 Oesophageal foreign body 5000138 M12.3 Oesophageal perforation 25000139 M12.4 Achalasia cardia 7000140 M12.5 Oesophageal Varices,variceal banding 10000141 M12.6 Oesophageal Varices, sclerotherapy 5000142 M12.7 Oesophageal Fistula 30000143 M12.8 GAVE (Gastric Antral Vascular Ectasia) 20000144 M12.9 Gastric varices 15000145 M12.10 Acute pancreatitis (Mild) 75,000146 M12.11 Acute pancreatitis (severe) 1,50,000147 M12.12 Acute Pancreatitis with pseudocyst (infected) 30000148 M12.13 Chronic pancreatitis with severe pain 20000149 M12.14 Obscure GI bleed 50000150 M12.15 Cirrhosis with Hepatic Encephalopathy 30000151 M12.16 Cirrhosis with hepato renal syndrome 40000

M12.17 Biliary stricture 152 M12.17.1 1)Post op stent 50000153 M12.17.2 2)Post op leaks 75000154 M12.17.3 3)Sclerosing cholangitis 75000

*Repeat procedures due to system separation.*Tax Deduction at Source (TDS) at the time payment as per prevailing IncomeTax Rules.

SPECIALNOTES ON PACKAGES

1. Renal packageo AV fistula and pre-transplant Haemo-dialysis are approved along with renal

transplant surgery only and not separately.o Hospital shall provide post transplant immunosuppressive therapy for 1st to 6th

month under Aarogyasri I and for 7th to 12th under Aarogyasri II.

2. Cancer package.o Chemotherapy and radiotherapy should be administered only by professionals

trained in respective therapies (i.e. Medical Oncologists and Radiation Oncologists) and well versed with dealing with the side-effects the treatment can cause.

o The Chemotherapy packages in Aarogyasri II are only supplementary to the packages in Aarogyasri I, hence they shall be used in association with Aarogyasri I packages.

o Patients with hematological malignancies- (leukemia’s, lymphoma’s, multiple myeloma) and pediatric malignancies (Any patient < 14 years of age) should be treated by qualified medical oncologists only.

54

o The advanced radiotherapy packages in Aarogyasri II shall be utilized only for the cases and diseases which do not respond to conventional radiotherapy package provided in Aarogyasri I.

o Each cycle cost includes• Cost of chemotherapy drugs • Hospital charges• All the infusional chemotherapy cancer cases must be treated as

inpatients only.• Doctors fees• Supportive care medications (i.e. i.v. fluids, steroids, H2 blockers, anti-

emetics)• All Investigations

o An average of Rs 2000 to Rs 5000/- has been added to the above cost, to cover for treatment of complications.o Tumors not included in this list, if have a chemotherapy regimen that is proven to be curative, or provide long term improvements in overall survival will be reviewed on a case by case basis by the technical committee of the Trust.

3. Polytrauma package Components of Polytrauma: The components of Polytrauma based on the system involved are: 1.Orthopedic trauma, 2.Neuro-Surgical Trauma, 3. Chest Injuries and 4. Abdominal InjuriesThe above components may be treated separately or combined as the case warrants. For providing insurance coverage to polytrauma cases requiring Hospitalization and/or Surgery for BPL families, management of each of the above can be classified as given below:

Orthopedic trauma 1. Surgical Corrections

Neuro-Surgical Trauma 1. Conservative2. Surgical Treatment

Chest Injuries 1. Conservative2. Surgical treatment

Abdominal Injuries 1. Conservative2. Surgical treatment

I. All cases, which require conservative management with a minimum of one-week hospitalization with evidence of (Imageology based) seriousness of injury to warrant admission, only need to be covered to avoid misuse of the scheme for minor/trivial cases.

II. In case of Neurosurgical trauma, admission is based on both Imageology evidence and Glasgow Coma Scale (A scale of less than 13 is desirable).III. All surgeries related to poly-trauma are covered irrespective of hospitalization period.IV. Initial evaluation of all trauma patients has to be free of cost.V. The conservative line of treatment in Orthopedics for specified procedures are covered in Aarogyasri II.

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4. Prostheses: i) Cost of prosthesis is inclusive of foot and shoe, wherever required.ii) Prosthesis must have been manufactured with the materials with BIS (Bureau

of Indian Standards) certification.iii) All prosthesis shall be functional in nature.iv) Manufacturer shall give minimum of 3 years replacement Guarantee.v) Manufacturer shall provide free replacement of leather parts/straps etc.,

during this period apart from replacement guarantee.

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ANNEXURE-VGENERAL GUIDELINES

In order to obtain feedback on Aarogyasri-I & II from service providers and resolve issues if any the Trust conducted a workshop with Network Hospitals on Rajiv Aarogyasri on 08.09.2008 .Representatives of the 319 Network Hospitals attended the meeting. A Core committee was formed after the workshop and the Committee met on 19.9.2008 and discussed the points raised in the workshop. Trust approved the following recommendations made by the Committee based on feasibility and benefit that will accrue to the BPL families.

A. HOSPITAL SERVICESi) Allocating minimum 25% of beds in network hospitals for Aarogyasri

patients: Network hospitals should make atleast 25% of their bed capacity available for occupation by Aarogyasri patients for treatment.

ii) Conduct of OP services:

a) Network hospitals should provide separate OP facilities for Aarogyasri patients, to be manned by “Medical Coordinator” of the hospital (RAMCO) and Aarogyamithra/s.

b) General counselling should be done for all OP patients to ascertain their eligibility under Aarogyasri to avoid later conversion of cash patients at a later date.

iii) Conversion of cash patients into Aarogyasri: Problems are arising when a patient is admitted in a network hospital as cash patient and later he / she claims free treatment under Aarogyasri. To avoid such cases, hospitals shall take a declaration from patient at the time of admission itself on the applicability or otherwise of Aarogyasri in his/her case. In emergency /trauma cases, patients may be allowed 48 hours after admission to claim Aarogyasri benefit.

iv) Specialities: Network hospital should normally not refuse to admit an Aarogyasri patient in any speciality where it has consultants and equipment. A minimum of 25% of overall bed capacity and of beds in each speciality have to be made available to Aarogyasri patients in network hospitals

v) Conduct of Health Camps: Network hospitals have to conduct Health Camps and adhere to the schedule as fixed by the Trust. In camps, hospitals need to educate people on preventive measures, distribute medicines and ensure coordination with Aarogyamithras and the concerned PHC / CHC doctors.

vi) Follow-up services to Aarogyasri Patients: Hospitals will be reimbursed pre-fixed amount for the medicines / tests / consultations that are given to patients as follow-up treatment, for identified diseases. (Please refer to detailed guidelines on patient follow-up)

B. NEW PACKAGES UNDER RAJIV AAROGYASRI- IITrust included another 77 New Packages to extend coverage in certain less covered areas such as Ophthalmology, ENT, vascular surgery and to make coverage more elaborate in critical areas such as Trauma, Cardiology etc. The details of usage guidelines of these packages are as follows.

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I. SURGICAL:

• Provision is now made for full coverage of wound management in Compound Fractures.

• Since it is wound management in compound fracture management, these packages must be used in association with fracture management of long bones in trauma either by Internal Fixation (ORIF) or by External Fixation.

• As separate package is provided for wound management in compound fracture the earlier package amount for External Fixation is reduced.

• Separate packages provided for surgical management of Facial Bone Fractures and Pelvic Bone Fracture in Trauma.

• Packages are provided for surgical management of Patella Fracture and small bone fractures in trauma; however these packages are applicable when these fractures are sustained as a component of Poly-Trauma i.e.in association with other injuries defined in poly trauma.

• Two more components for Intestinal Perforation are added Viz. Duodenal Perforation and Appendicular Perforation to clearly define this surgical emergency.

• Packages are provided for Complicated Eclampsia, Abruption placenta, and other Common life threatening emergencies in obstetrics.

• More procedures are now covered for management of Trigeminal Neuralgia and Aneurysms in Neuro-Surgery.

• Coverage for Staghorn Calculus is provided in Renal Segment.

• Coverage is made more extensive in Ophthalmology, ENT and Vascular Surgery.

II. MEDICAL:

• More life saving emergencies such as Septic shock, Cerebral Malaria, Tuberculosis Meningitis, Snake Bite and Scorpion Sting etc., are included in Medical Emergencies.

• Coverage for Acute MI is made elaborate to cover complications associated with it.

• Coverage for critical care in children is extended to multiorgan failure and ARDS

• Common complication in SLE viz. Sepsis is covered with separate package

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III. HEARING IMPAIRED:

• In order to facilitate treatment for large number of Hearing Impaired patients under Rajiv Aarogyasri-II, coverage is provided for Behind Ear Analogue Hearing Aid.

C. RATIONALIZATION OF PACKAGESIn order to regulate proper usage of certain laparoscopic packages, to update changes in treatment protocols and to give clarity to some packages, rationalization of certain existing packages were done by technical committee.

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ANNEXURE - VI

AAROGYASRI HEALTH CARE TRUST

Follow-up Services for Aarogyasri beneficiaries

Rajiv Aarogyasri Scheme aims at providing coverage for follow-up services, wherever specifically needed by providing system / disease specific package for follow-up for consultation, investigations, drugs etc. for one year.

Patients require follow-up services for certain procedures in order to gain optimum benefit from the Surgery/Therapy and to avoid complications. Presently Trust is providing follow-up drugs to these beneficiaries through Network Hospitals, but changes in the follow-up services are required in order to streamline the services.

Hence the technical committee of the Trust in consultation with specialists identified specific procedures for follow-up, reviewed the present policy and suggested change by providing system / disease specific package. Accordingly the following guidelines and packages are formulated for follow-up services by Network Hospitals under the scheme from 14th November 2008.

GUIDELINES

• Package covers entire cost of follow-up. ,i.e., consultation, medicines, diagnostic tests etc.,

• Follow-up treatment shall be entirely cashless to the patient and will start on 11th

day after his discharge and will continue for one year after 11th day of discharge.• No formal pre-authorization is required.

• For operational convenience package amount is apportioned to 4 quarters. Since frequency of visits and investigations are common during first quarter, more amount is allocated for first instalment

• However the entire package amount must be treated as single entity and hospital shall not refuse to conduct investigations free of cost under the package any time during one year follow-up period.

• Patient follow-up visits may be spaced according to medical requirement, but approval will be given for one quarter.

• RAMCO along with AAROGYAMITHRA shall facilitate patient follow-up.

PROCESS FLOW

1. Patient is counselled at the time of discharge about the importance of followup and availability of free services by the hospital

2. The first follow-up date shall be on 11th day after discharge as first 10 days treatment is provided to the patient as per disease package. The date and other details shall be indicated in the online Discharge Summary.

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3. RAMCO and AAROGYAMITHRA shall specifically inform the patient about the date and time of subsequent follow-up visits, duly making entry in patient follow-up in the trust portal based on standard medical protocols.

4. Hospital shall send proof of follow-up services of patient and submit to Trust once in three months for each quarter by uploading the following in the Trust portal: (see the work flow for follow-up also)

• Details of consultation

• Details of Medicines given

• Investigations done

• Acquaintance from patients in the prescribed format

• Photograph showing receipt of Medicines to the patient

• Bills for medicines and diagnostics (to be scanned and uploaded)

5. Trust shall settle claim as per package amount based on above proof.

6. Hospital shall claim follow-up package only for the disease mentioned along with the code and no other claim shall be entertained by Trust.

Follow-up packages FOLLOWUP PACKAGES-SURGICAL

S.No. Code SYSTEM Package1st Instalment

Subsequent3instalments

1 SF1.1.5.6 Total Thyroidectomy 3000 1200 6002 SF1.4.2 Portocaval Anastomosis 10000 4000 2000

3 SF1.6.1Operation of Adernal

4000 1600 800glands bilateral

4 SF1.7.2Splenorenal

10000 4000 2000Anastomosis5 SF1.7.3 Warren shunt 10000 4000 2000

6 SF6.8.2

Spleenectomy + Devascularisation + Spleno Renal Shunt 10000 4000 2000

7 SF6.9.1Lap- Pancreatic Necrosectomy 8000 3500 1500

8 SF6.9.3Pancreatic Necrosectomy (open) 8000 3500 1500

9 SF7.1.1.1 Coronary Balloon Angioplasty 10000 4000 200010 SF7.1.7.1 Renal Angioplasty 10000 4000 200011 SF7.1.7.2 Peripheral Angioplasty 10000 4000 200012 SF7.1.7.3 Vertebral Angioplasty 10000 4000 200013 SF7.2.1.1 Coronary Bypass Surgery 10000 4000 2000

14 SF7.2.1.2Coronary Bypass Surgery-post Angioplasty 10000 4000 2000

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15 SF7.2.1.3 CABG with IABP pump 10000 4000 200016 SF7.2.1.4 CABG with aneurismal repair 10000 4000 200017 SF7.2.9.1 With Prosthetic Ring 10000 4000 200018 SF7.2.9.2 Without Prosthetic Ring 10000 4000 200019 SF7.2.9.3 Open Pulmonary Valvotomy 10000 4000 200020 SF7.2.9.4 Closed mitral valvotomy 10000 4000 200021 SF7.2.9.5 Mitral Valvotomy (Open) 10000 4000 2000

22 SF7.2.10.1Mitral Valve Replacement (With Valve) 10000 4000 2000

23 SF7.2.10.2Aortic Valve Replacement (With Valve) 10000 4000 2000

24 SF7.2.10.3 Tricuspid Valve Replacement 10000 4000 2000

25 SF7.2.10.4Double Valve Replacement (With Valve) 10000 4000 2000

26 SF7.2.19.1 Carotid Embolectomy 10000 4000 200027 SF8.6.4 Encephalocele 4000 1600 800

28 SF8.8.12Surgeries on adrenal glands in Children 4000 1600 800

29 SF9.2.1 Open Pyelolithotomy 2000 800 40030 SF9.2.2 Open Nephrolithotomy 2000 800 40031 SF9.2.3 Open Cystolithotomy 2000 800 40032 SF9.2.4 Laparoscopic Pyelolithotomy 2000 800 40033 SF9.3.1 Cystolithotripsy 2000 800 40034 SF9.3.2 PCNL 2000 800 40035 SF9.3.3 ESWL 2000 800 40036 SF9.3.4 URSL 2000 800 400

37 SF9.7.1Endoscope Removal of stone in Bladder 2000 800 400

38 SF9.9.1Transurethral resection of prostate (TURP) 2000 800 400

39 SF9.9.2 TURP Cyst lithotripsy 2000 800 40040 SF9.9.3 Open prostatectomy 2000 800 400

41 SF10.1.1Craniotomy and Evacuation of Haematoma –Subdural 8000 3200 1600

42 SF10.1.2Craniotomy and Evacuation of Haematoma –Extradural 8000 3200 1600

43 SF10.1.3Evacuation of Brain Abscess-burr hole 8000 3200 1600

44 SF10.1.4

Excision of Lobe (Frontal,Temporal,Cerebellum etc.) 8000 3200 1600

45 SF10.1.5Excision of Brain Tumor Supratentorial 8000 3200 1600

46 SF10.1.6 Parasagital 8000 3200 160047 SF10.1.7 Basal 8000 3200 1600

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48 SF10.1.8 Brain Stem 8000 3200 160049 SF10.1.9 C P Angle Tumor 8000 3200 160050 SF10.1.10 Other tumors 8000 3200 1600

51 SF10.1.11Excision of Brain Tumors –Subtentorial 8000 3200 1600

52 SF10.1.12Ventriculoatrial /Ventriculoperitoneal Shunt 8000 3200 1600

53 SF10.1.14 Subdural Tapping 8000 3200 160054 SF10.1.15 Ventricular Tapping 8000 3200 160055 SF10.1.16 Abscess Tapping 8000 3200 160056 SF10.1.17 Vascular Malformations 8000 3200 160057 SF10.1.18 Peritoneal Shunt 8000 3200 160058 SF10.1.19 Atrial Shunt 8000 3200 160059 SF10.1.20 Meningo Encephalocele 8000 3200 160060 SF10.1.21 Meningomyelocele 8000 3200 160061 SF10.1.25 Ventriculo-Atrial Shunt 8000 3200 160062 SF10.1.26 Excision of Brain Abcess 8000 3200 160063 SF10.1.27 Aneurysm Clipping 8000 3200 1600

64 SF10.1.28External Ventricular Drainage (EVD) 8000 3200 1600

65 SF10.3.2 Trans Sphenoidal Surgery 8000 3200 160066 SF10.3.3 Trans Oral Surgery 8000 3200 160067 SF10.4.1 Endoscopy procedures 8000 3200 1600

68 SF10.4.2Intra-Cerebral Hematoma evacuation 8000 3200 1600

69 SF10.7.1 Temporal Lobectomy 8000 3200 160070 SF10.7.2 Lesionectomy type 1 8000 3200 160071 SF10.7.3 Lesionectomy type 2 8000 3200 1600

72 SF10.7.4Temporal lobectomy plus Depth Electrodes 8000 3200 1600

73 SF15.2.1.1Stay in General Ward@Rs.500/day 8000 3200 1600

74 SF15.2.1.2Stay in Neuro ICU@Rs.4000/day 8000 3200 1600

75 SF15.2.2 Surgical Treatment (Up to) 8000 3200 1600

FOLLOWUP PACKAGES-MEDICAL

S.No. Code Disease Package 1st Inst.Subsequent

3 inst.

1 MF1.1Acute severe asthma

10000 4000 2000with Acute respiratoryFailure

2 MF1.2COPD Respiratory Failure (infective exacerbation)

10000 4000 2000

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3 MF4.1.12

Term baby with persistent pulmonary hypertension Ventilation-HFO Hyperbilirubinemia Clinical sepsis

6000 3000 1000

4 MF4.1.16Term baby with seizures ventilated

5000 2000 1000

5 MF4.2.1.5Acute Severe Asthma

4000 1600 800(Ventilated)

6 MF4.2.2.5 Infective Endocarditis 10000 4000 2000

7 MF4.2.3.1Meningo- encephalitis

6500 2000 1500(Non Ventilated)

8 MF4.2.3.2Meningo- encephalitis

6500 2000 1500( Ventilated)

9 MF4.2.3.3 Status Epilepticus 6500 2000 150010 MF4.2.3.5 Intra cranial bleed 6500 2000 1500

11 MF4.3.2.1Congenital heart disease with congestive cardiac failure

5000 2000 1000

12 MF4.3.2.2Acquired heart disease with congestive cardiac failure

5000 2000 1000

13 MF4.3.3.1Steroid Resistant Nephrotic syndrome 5000 2000 1000Complicated or Resistant

14 MF4.3.4.3 Anemia of unknown cause 5000 2000 100015 MF4.3.5.1 Pyogenic meningitis 5000 2000 100016 MF4.3.5.2 Neuro tuberculosis 5000 2000 1000

17 MF4.3.5.3Neuro tuberculosis with ventilation

5000 2000 1000

18 MF4.3.6.1Convulsive Disorders/Status Epilepticus (Fits)

5000 2000 1000

19 MF4.3.6.3Encephalitis / Encephalopathy

5000 2000 1000

20 MF5.1.1Acute Mi (conservative Management without Angiogram)

10000 4000 2000

21 MF5.1.2Acute Mi (conservative Management with Angiogram)

10000 4000 2000

22 MF5.1.3Acute Mi with cardiogenic shock

10000 4000 2000

23 MF5.1.4Acute Mi with requiring labp Pump

10000 4000 2000

24 MF5.1.5 Refractory Cardiac Failure 10000 4000 2000

25 MF5.2 Infective Endocarditic 10000 4000 200026 MF5.4 Complex Arrhythmias 10000 4000 200027 MF6.2 Nephritic Syndrome 5000 2000 1000

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28 MF7.1ADEM or Relapse in Multiple sclerosis

5000 2000 1000

29 MF7.2 CIDP 5000 2000 100030 MF7.3 Hemorrhagic Stroke/Strokes 5000 2000 100031 MF7.4 Ischemic Strokes 5000 2000 1000

32 MF7.6NEUROINFECTIONS -Fungal Meningitis

5000 2000 1000

33 MF7.7NEUROINFECTIONS -Pyogenic Meningitis

5000 2000 1000

34 MF7.8

NEUROINFECTIONS -Viral Meningoencephalitis ( Including Herpes encephalitis)

5000 2000 1000

35 MF7.9Neuromuscular (myasthenia gravis)

4000 1600 800

36 MF8.4 Interstitial Lung diseases 10000 4000 200037 MF8.5 Pneumoconiosis 10000 4000 2000

38 MF9.1Pemphigus /

3500 1400 700Pemphigoid

39 MF10.1SLE (Systemic Lupus Erythematosis)

6000 2400 1200

40 MF10.2 Scleroderma 6000 2400 1200

41 MF10.3MCTD (Mixed Connective Tissue Disorder)

6000 2400 1200

42 MF10.4 Primary Sjogren’s Syndrome 6000 2400 1200

43 MF10.5 VASCULITIS 6000 2400 120044 MF11.2.1 Hypopitutarism 8000 3500 150045 MF11.2.2 Pituitary - Acromegaly 6500 2000 1500

46 MF11.2.4

Delayed Puberty Hypogonadism

7000 2500 1500(ex.Turners synd, Kleinfelter synd)

47 MF12.9 Gastric varices 7000 2500 1500

48 MF12.13Chronic pancreatitis with severe pain

7000 2500 1500

49 MF12.15Cirrhosis with Hepatic Encephalopathy

7000 2500 1500

50 MF12.16Cirrhosis with hepato renal syndrome

7000 2500 1500

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ANNEXURE –VII

GUIDELINES FOR POLYTRAUMA CASES

In order to rescue the poor patients involved in road traffic accidents causing serious injuries and requiring hospitalization /surgery, Government have decided to provide financial assistance under Rajiv Aarogyasri Community Health Insurance Scheme. Accordingly Aarogyasri Health Care Trust in consultation with experts from the respective specialties both from Government and private sectors formulated the following Guidelines and Packages for these cases.

I. Components of Polytrauma

The following are the major components of polytrauma based on the systems involved

1. Orthopedic Trauma2. Neuro-Surgical Trauma3. Chest Injuries4. Abdominal Injuries

The above major components separately or combined are defined as Poly-Trauma since Trauma cases are mostly associated with other minor injuries along with the major components.

II. Coverage under Polytrauma

Following are the identified components of Polytrauma for providing coverage under Aarogyasri scheme.

Orthopedic Trauma 2. Surgical Corrections

Neuro-Surgical Trauma 3. Conservative4. Surgical Treatment

Chest Injuries 3. Conservative4. Surgical treatment

Abdominal Injuries

3. Conservative4. Surgical treatment

• Initial diagnostic evaluation for all trauma patients have to be made free of cost.• Since majority of poly trauma cases are emergency in nature emergency pre-

authorization may be obtained by providing basic data and white card/health card number if available (see the details in emergency E-preauthorization module)

• Hospital shall give minimum 48 hours time for the patient to get into the scheme on provision of health card/ white card. Till that time no money in the form of advance shall be collected.

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• After patient stabilizes hospital can provide full details like mode of injury and type of injuries sustained in respective columns of pre-authorization to help assess the case by doctors approving preauthorization.

• Hospital shall provide the plan of management along with details of surgery/surgeries contemplated on the patient in remarks column of pre-authorization.

CONSERVATIVE MANAGEMENT

All cases of conservative management shall fulfill the following criteria

• Require a minimum of one-week hospitalization • Evidence of (Imageology based) seriousness of injury to warrant admission.• In case of Conservative Management in Neurosurgical trauma, admission is

based on both Imageology evidence and Glasgow Coma Scale (A scale of less than 13 is desirable).

• All packages in conservative management are based on average hospital stay in both ICU and General Ward. However hospital shall note that the maximum package days permitted in ICU and General Ward stay under the scheme are only indicative days and hospital shall facilitate treatment in respective wards till patient recovers completely irrespective of number of days under these packages.

• Hospital either can claim maximum amount under each category of hospital stay i.e in ICU and General Ward or for the probable number of days stay in respective wards, but claim shall be settled as per number of days of actual stay.

SURGICAL MANAGEMENT

All surgeries related to the components of poly-trauma and mentioned in packages are covered irrespective of hospitalization period.

1. All surgical packages are maximum amounts that can be claimed under that category and claim shall be settled based on the type of surgery performed, number of days of hospital stay and associated injuries treated that are not defined in the scheme.

2. Pre-Authorization shall be given for full amount and claim shall be settled as per above guidelines

3. Package for Surgical Correction of Long bone is for each bone and hospital can claim multiples of the package amount for multiple fractures sustained. However for both bones fractures in forearms and legs the second package shall be halved as procedure involved for second bone is minor and involves same field of operation and same sitting.

4. Separate package is provided for coverage of wound management in Compound Fractures. Since it is wound management in compound fracture, these packages shall only be used in association with fracture management of long bones in trauma either by Internal Fixation (ORIF) or by External Fixation.

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5. As separate package is provided for wound management in compound fracture the earlier package amount for External Fixation is reduced.

6. Separate packages are provided for surgical management of Facial Bone Fractures and Pelvic Bone Fracture in Trauma.

7. Packages are provided for surgical management of Patella Fracture and small bone fractures in trauma; however these packages are applicable only when these fractures are sustained as a component of Poly-Trauma i.e.in association with other injuries defined in poly trauma.

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ANNEXURE VIII

GUIDELINES FOR ANALOGUE BEHIND-THE-EAR HEARING AID HOSPITAL INFRASTRUCTURE

Shall have full time services of ENT Surgeon and Audiologist Shall have facilities for Pure tone Audiogram and Impedance AudiogramShall have sound proof room to conduct Audiometry. Shall have a well established Audiology department along with fully equipped ear mould laboratory to make soft ear moulds.Shall have fully equipped Hearing aid repair section

HOSPITAL RESPONSIBILITIES • Provide cashless services under the scheme viz. audiological evaluation,

investigation, suitable hearing aid, regular supply of batteries for two years, pre and post hearing aid fitting counselling and regular follow up for a period of 3 years.

• Shall provide free of cost, regular maintenance services for a period of 3 years to the beneficiaries from the date of fitting of the Hearing aid.

• Shall provide the batteries, free of cost, to the beneficiary for two years.

• Shall provide free replacement and repair of parts/defects of instrument for a period of 3 years.

• Shall replace the defective Hearing aids free of cost during the mandatory guarantee period specified by the Trust i.e., 3 years

• Since average life of the hearing aid is 5 years, hospital shall not raise second pre-authorization for same patient within this period unless authorized by the technical committee on medical grounds

• Shall arrange for pre and post fitting counselling of child and parents in case of children

• Beneficiary shall be properly counselled about proper handling and usage of the HEARING AID and provide a written Dos and Don’ts to the patient in local language

• Shall provide standard equipment with standard specifications as detailed below and 3 years warranty and shall see that spares and services are available locally

• Instrument with following Specifications approved by Technical committee only shall be used.

1. Two models (Trimmer Digital Type)Model1-Mild Category-Gain 20 db to 50 dbModel2-Strong Category-Gain 40 db to 80 db

2. Power Consumption

Mild Category- <5mamp.Strong Category-<15 mamp.

3. Frequency Response – 250 Hz to 3510 Hz (ISO Standard)

4. Adjustable Potentiometer for

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Automatic Gain Control(AGC)Maximum Peak Output(MPO)

5. Extra Hook and Extra Ear Tips

• Shall provide free custom made soft ear moulds to beneficiary.

• Shall select the beneficiary based on the criteria laid down by the TRUST.

• Shall follow the guidelines in providing treatment to beneficiaries mentioned here under:

1) To allow one Audiologist and ENT surgeon from the concerned hospitals as “observers” during evaluation of the cochlear committee.

2) To give more weightage for children below the age of 3 years as early intervention can bring in better results.

3) Early re-counselling of patients who were kept pending within 3 weeks.

4) To give special training programme of parents / patient children at Govt. ENT hospital, Hyderabad for counselling in pending cases on request from concerned hospital.

5) To conduct a weekly meeting exclusively to screen and complete the pending cases.

6) To physically evaluate AV therapy cases for payment.

7) To extend the intimation period of informing the concerned hospitals with regard to schedule of committee meeting from two days to four days.

Eligibility Criteria1. Children suffering from hearing loss either congenital or acquired type who cannot

be treated either medically or surgically to overcome the hearing loss are eligible for the sanction of “Behind ear hearing aids”.

2. Pre-lingual deaf children in the age group 0 to 5 years

3. Students identified with deafness attending the normal school in the age group of 5 to 15 years.

4. Any other person having hearing loss who requires the use of hearing aid.

5. Motivation on the part of the child/person to use Hearing aid Investigations required:

Investigations required:1. Pure tone Audiogram

2. Impedance Audiogram

3. Assessment of the language and speech of the child.

4. Certification by the Audiologist with regard to the type and gain of the “behind the ear hearing aid” to be used.

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ANNEXURE - IX

GUIDELINES FOR LAPAROSCOPIC PROCEDURES

1. Hospitals shall upload intra-operative photographs depicting face of the patient and operative site along with specimen removed with date and time depicted on the print/image.

2. Hospitals shall upload intra-operative video endoscopic recording of entire procedure along with claims attachment. The CD should be converted to Webex Recorded format available in hospital login.

GUIDELINES FOR OBSTETRICS, GYNAECOLOGY

Trust conducted a workshop of Gynecologists both from Government and the Private sector on 28.01.2010. Based on the suggestions of the experts in the meeting and the recommendations of the expert committee constituted thereafter the following revised guidelines for taking up Hysterectomy and other Gynecological Procedures under Aarogyasri are being issued:

A. Women Below 35 years: Preauthorization for HYSTERECTOMIES will be given only if she is suffering from:

1.CIN III (Colposcopic picture and Histopathological Examination report are

mandatory).

B. Women in the age group of 35 – 40 Years: Preauthorization for

HYSTERECTOMIES will be given only if she is suffering from:

1. Cervical Intraepithelial Neoplasia (CIN III).2. Symptomatic fibroid uterus: Objective evidence of Anemia or pressure

symptoms.3. Pelvic organ Prolapse III degree & Procidentia.

C. Women in the age group of 40 – 45 Years: Preauthorization for HYSTERECTOMIES will be given only if she is suffering from:

1. Cervical Intraepithelial Neoplasia (CIN III).2. Symptomatic fibroid uterus: Objective evidence of Anemia or pressure

symptoms.3. Pelvic organ Prolapse III degree & Procidentia.4. Abnormal Uterine Bleeding:

• Women with history and evidence of 6 months of conservative treatment in any Hospital (Please section E for details). D&C is mandatory with Histopathology report of complex hyperplasia with or without atypia.

D. Women more than 45 Years of age Preauthorization for HYSTERECTOMIES will be given only if she is suffering from:

Cervical Intraepithelial Neoplasia (CIN III).2. Symptomatic fibroid uterus: Objective evidence of Anemia or pressure

symptoms.71

Pelvic organ Prolapse III degree & Procidentia.Abnormal Uterine Bleeding:

• Women with history and evidence of 6 months of conservative treatment in any Hospital. D&C is mandatory with Histopathology report of complex hyperplasia with or without atypia.

5. Post menopausal bleeding with endometrial hyperplasia with D&C report. • Complex hyperplasia or complex hyperplasia with atypia or USG evidence of endometrial Polyp (USG picture) with previous hysteroscopic polypectomy with histopathology report showing complex hyperplasia with or without atypia.

E. Other Guidelines :

i. Uterus with transverse diameter/vertical diameter of more than 120mm will not be approved for Laparoscopic procedure.

ii. Whenever the Post-operative HPE shows evidence of malignancy the patient shall be referred to the nearest Cancer Treatment Centre, with a referral letter. The RAMCO and Aarogyamithra of the Network Hospital should facilitate the referral of the patient to the Cancer Centre empanelled under Aarogyasri. The Aarogyamithra will co-ordinate with the Aarogyamithra of the Cancer Centre in this regard.

iii. All cases should have a history of at least six (6) months of conservative management in any Hospitals. The evidence for the same has to be submitted as follows:

1. For an Aarogyasri Network Hospital: The OP details captured in the Aarogyasri workflow along with case documents for six (6) months prior to sending preauthorization for the procedure will be verified.

2. For Hospitals outside Aarogyasri network: Case sheet or other case documents to prove the patient has received conservative treatment prior to sending the preauthorization will be verified.

iv. Video Recording (in WebEx format) of Pre-operative counseling of the patient with treating doctor, RAMCO and patients relative is mandatory for giving Pre-authorization. The attachment shall be made in the counseling documents/video attachments slot in the online workflow at the time of sending the case for preauthorization. The consent form shall be in local language (patient’s mother tongue).

v. Only qualified Obstetricians & Gynecologists trained in Laparoscopy shall perform LAVH. All the Obstetricians & Gynecologists in the scheme shall submit their Laparoscopic experience attested by the endoscopic committee of FOGSI within 3 months of issue of guidelines.

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vi. Only Hospitals having Laparoscopic equipment, bipolar cautery, carboflator, a generator with sufficient monitoring equipments & qualified anesthetist shall be empanelled into the scheme.

vii. In all LAVH cases, follow-up of the patient on 10th and 21st day of discharge free of cost is mandatory and claim shall be preferred only after 21 days of discharge with histopathology report. Further, any complications within 21 days should be treated free of cost.

viii. If there is a deviation from the pre-auth approved while conducting the surgery the same shall be informed to the Trust telephonically immediately and raise another pre-auth indicating the change of procedure and simultaneously cancelling the pre-auth which was earlier approved.

ix. If the Post operative stay after LAVH is more than 5 days, the reasons have to be recorded in the case sheet failing which the claim of the hospital will not be considered.

x. No additional surgeries on any other organ of GIT like gall bladder or appendix shall be performed simultaneously with Hysterectomy or vice versa as it is not medically acceptable.

xi. For approval of Gynecological procedures, the Network Hospital should have functioning Obstetric unit also.

xii. Lap. Cystectomy or Adnexectomy shall be treated alike for preauthorization.

xiii. The pre-auth approval is given for only Hysterectomy. If Oopherectomy is decided in addition, justification has to be provided by the treating doctor and accept the responsibility for Oopherectomy along with histopathology report.

The network hospitals may note that the above guidelines will come in to force for all preauthorisations being submitted from 00:00 hrs of 26.04.2010. These guidelines supersede the guidelines issued on 13.05.2009.

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ANNEXURE - X

GUIDELINES FOR GENITO-URINARY PROCEDURES

1. All symptomatic ureteric stones measuring more than 6mm only shall be taken up for lithotripsy procedures.

2. Radiological proof of stone in USG/KUB/IVP/CT scan with clear mapping of size shall be provided in case of renal/ ureteric / vesicle calculi for approval for lithotripsy procedures.

3. Plain CT scan is required in cases of radiolucent renal/ ureteric calculi which cannot be proved otherwise.

4. Hospitals shall upload intra-operative video endoscopic recording for all endoscopic procedures at the time of submission of claims. The CD should be converted to WebEx recorded format available in hospital login.

5. All post operative photographs shall show the face & operative scar in the same photograph.

6. Photograph clearly showing the face of the patient lying on procedure table shall be uploaded in all cases of lithotripsy procedures.

7. All cases of TURP, it is desirable to have minimum of 100 post void urine or flow of < 10 uroflowmetry reading.

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ANNEXURE - XI

GUIDELINES FOR SELECTION OF CASES FOR ADVANCED RADIOTHERAPY PROCEDURES

S13.4 SPECIALIZED RADIATION THERAPY

Specialized radiation therapy like IMRT involves combinations of several intensity-modulated fields coming from different beam directions to produce a custom tailored radiation dose that maximizes tumor dose while also protecting adjacent normal tissues.

These facilities should be confined to deserving patients only according to the packages specified. The Hospitals utilizing this therapy should have a qualified team which includes the radiation oncologist, medical radiation physicist, dosimetrist, radiation therapist and radiation therapy nurse.

It is mandatory that the hospitals utilize the Specialized Radiation Therapy services for the below mentioned specific conditions so that needy patients are benefited.

S.NO. SYSTEMSPECIAL

INVESTIGATION

PACKAGES

POST OPERATIVE/PROCEDURE

INVESTIGATIONS13.4.1 IMRT (Intensity modulated radiotherapy)

IBrain Tumors

AUnifocal Malignant gliomas (Primary) Biopsy &

CT/MRI (Pre-Auth)

1,00,000USG/CT/Tumor Marker/RT Treatment Charts

BLow grade astrocytoma (PO) with residual lesion

C Optic nerve glioma

IIHead and Neck Cancers (Early T1, T2 Lesions N0, M0)

Biopsy & Clinical photo (for Pre-Auth)

1,00,000USG/CT/Tumor Marker/RT Treatment Charts

A Ca. TonsilB Ca. Soft PalateC Ca. UVULAD Ca. Base of tongueE Ca. Vallecula

III Ca. NasopharynxBiopsy, CT scan (MRI for Pre-Auth)Isotope Bone scan for surgery/PET Scan

1,00,000USG/CT/Tumor Marker/RT Treatment Charts

IV Ca. Para Nasal Sinuses 1,00,000USG/CT/Tumor Marker/RT Treatment Charts

V Ca. Prostate – Non metastasis & Low risk

1,00,000 USG/CT/Tumor Marker/RT Treatment Charts

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VISuperior sulcus syndrome (CT scan + Biopsy) is required

1,00,000USG/CT/Tumor Marker/RT Treatment Charts

VII Orbital Rhabdo Myorcoma 1,00,000USG/CT/Tumor Marker/RT Treatment Charts

S13.4.2 3DCRT (3-D conformational radiotherapy)

I Brain Tumors

ALow grade glioma (Post-operative) residual lesion

Biopsy, CT/MRI for (Pre-Auth)

75,000USG/CT/Tumor Marker/RT Treatment Charts

BMedulloblastoma (Post-operative)

CEvendymorna (Post-operative)

IICa. Prostate – Non metastatic & low risk

Biopsy, CT/MRI Bone scan for (Pre-Auth)/PET Scan

75,000USG/CT/Tumor Marker/RT Treatment Charts

IIIHead & Neck Cancer (T1, T2 lesions only)

Biopsy, CT/MRI for (Pre-Auth)

75,000USG/CT/Tumor Marker/RT Treatment Charts

A Ca. TonsilB Ca. Soft PalateC Ca. UVULAD Ca. Base of TongueE Ca. Vallecula

IVSuperior sulcus syndrome, CT scan/MRI and Biopsy is required.

Biopsy, CT/MRI for (Pre-Auth)

75,000USG/CT/Tumor Marker/RT Treatment Charts

V Orbital Rhabdo myo sarcoma 75,000USG/CT/Tumor Marker/RT Treatment Charts

VIRetino Blastoma-Non-metastatic, unilateral/bilateral

75,000USG/CT/Tumor Marker/RT Treatment Charts

VIIPediatric abdominal neuroblastoma (non-metastatic)

75,000USG/CT/Tumor Marker/RT Treatment Charts

S13.4.3 SRS/SRTStereotactic Radiosurgery:SRS

IAVM (Arterio-Venous Malformation)

MR Angiogram for diagnosis required for (Pre-Auth)

75000

Clinical photo with patient on treatment couch with SRS/SRT frame should be provided for all of the above for claim.

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Stereotactic Radiotherapy: SRT

IPituitary adenoma (Post Operative)

CT&MRI & (Pre-Auth)

75,000

USG/CT/Tumor Marker/RT Treatment Charts

Clinical photo with patient on treatment couch with SRS/SRT frame should be provided for all of the above for claim.

IILow grade glioma (Post Operative)

III Meningioma (Post Operative)

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ANNEXURE - XII

GUIDELINES FOR COCHLEAR IMPLANTATION

Under the scheme financial assistance to the tune of Rs.6.5 lakhs is being provided to the BPL patients undergoing cochlear implantation surgery and auditory verbal therapy for the totally deaf children below 12 years of age in the identified Network Hospitals. Since these children are likely to have multiple congenital malformations in association with deafness and both parents and child need to be counseled and evaluated (Pre-Implant Counseling and Evaluation) by the Network Hospital, it is imperative to confirm their fitness to under go surgery and get benefited from the therapy. Hence Trust resolved to screen these patients by a team of specialists in the field before pre-authorization approval is given to the Network Hospital to perform surgery.

The Trust constituted a committee and the Committee after detailed discussion formulated following guidelines to be followed by Network Hospitals.

1.0 HOSPITAL INFRASTRUCTURE

1.1 Hospital shall have services of well trained ENT Surgeon in Cochlear Implant Surgery and well equipped theatre facility with following equipment

.i. Operating microscope --- Two numbersii. Skeeter drill for Cochleostomy ---- Two numbersiii. Benair micro motor ---- Two numbersiv. Facial nerve monitor ---- One numberv. Two sets of micro ear surgery instruments - Two setsvi. Laser Co2 Lumens surti touch --- One number

1.2 Audiology and Audio-Verbal Rehabilitation set-up

There should be a well-established Audiology Department along with Audio-Verbal Rehabilitation Unit set-up with following qualified, regular personnel and equipment.

1.2.1 Personnel

a) An Audiologist and / Speech Pathologist (one post) with masters degree in Audiology and / or Speech, Language Pathology from any recognized institution.

b) An Audio-Verbal Rehabilitation specialist- one post-- well versed in audio verbal therapy techniques and software used in such methods. He/She should have undergone training from recognized institutions or persons accredited with imparting AVT for very young hearing handicapped children. The mother tongue of the specialist should be Telugu and should know how to write and read the Telugu language. He / She must be proficient in teaching Telugu Grammar.

1.2.2 Equipment

a) Audiology Equipment:

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The following equipment is absolutely necessary and should be available in the network hospital in order to conduct various types of audiological assessments to decide the andidacy for cochlear implantation and thereafter for audio verbal rehabilitation therapy work.

i) Pure tone audiometer ………………………. oneii) Free field equipment ………………………….one setiii) Impedance audiometer ……………………… oneiv) Oto-Acoustic Emission audiometer………… onev) ABR with Auditory Steady State Response Audiometer… onevi) Dedicated Computer system with internet facility (minimum 2mbpsvii) Connection), Digital Camera, Printer, Scanner etc.viii) Personnel programming systems for mapping and programming approved

types of cochlear implants.ix) Visible Speech Instrument with latest soft ware for imparting the audio

verbal therapy (One unit)x) Various teaching aids used for teaching language…….One setxi) There should be two sound treated rooms to accommodate the above

audiological equipment and for carrying out the periodic cochlear implant mapping work. The size of the each room should be 14'x12'. The sound treated rooms should be two-room set-up with negligible electrical static activity with ambient noise levels below 25 dB.

xii) There should be a separate well ventilated 10'x10' room exclusively for imparting the audio-verbal therapy along with teaching aids in which the child, therapist and the mother of the child should participate.

2.0 PRE-DIAGNOSTIC PROTOCOL

2.1 Guidelines for Candidate selection

2.1.1 Audiological and Medical Criteria

a) This scheme is applicable to children suffering from total deafness either,a. Pre-lingual- before acquiring speechb. Post lingual: - after acquiring speech

b) The age group covered is 0 to 12 years. c) Younger the age group better would be the benefits from Cochlear Implantation.

Further the age mentioned in the ration card/health card is the age of the child at the time of issue of ration card. Hospitals shall cross check the actual age as on date and can use the birth certificate for verification if required.

d) Cochlear implant may not be the first choice when considering deaf children above 2 years of age. Proof of having used conventional hearing aids along with details of process of speech therapy that they underwent from accredited rehabilitation personnel may be produced. If not, the hospital shall take necessary steps to give hearing aid under the existing Government schemes and speech therapy for sufficient time before advising cochlear implantation.

e) These deaf children must have used hearing aids. If no benefit is derived from the use of Conventional hearing aids either in terms of better hearing or acquisition of adequate language or communication skills then they should be considered for CI. Here the motivation on part of the child to express through speech by imitation is an important factor to be considered.

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f) These children should be free from any developmental delays and other sensory and oro-facial defects. These children should not have autistic tendencies.

g) The deaf children at least should have had developed some language and attempting to communicate through speech for basic needs. Children who are used to alternate mode of communication like gestures and signs and poorly motivated to use speech communication are poor candidates for cochlear implantation.

h) The deaf Children with abnormal Cochlear/ malformed Cochlear are not considered for Cochlear Implantation. The decision of the Technical committee is final in this mater.

i) Children with active middle - ear infection should be considered for Cochlear implantation only after middle - ear pathology is resolved.

j) In addition the following other criteria to be followed for selection of children between 6-12 years of age group

1. Children having profound hearing loss due to infections and other pathology in post-lingual group, who are not benefited even after usage of conventional hearing aid.

2. Children having congenital profound hearing loss and not benefited even after usage of any other hearing aid.

3. Children who are used to oral-aural method of communications and perusing inclusive education.

2.1.2 Audiological Investigation Protocol.

The children must undergo following essential diagnostic tests at hospital own centre with qualified personnel handling and reporting.

a) Behavior Observation Audiometry (BOA)

b) Puretone Audiometryc) Impedance audiometryd) Oto-acoustic Emission Audiometrye) ABR and ASSR test reportf) Aided Audiogramg) Assessment of language and speech development.

2.1.3 Radiological Investigation ProtocolThe following radiological investigations should be done to these children before sending for pre-authorization.

a. MRI Cochleab. CT Scan of Temporal Bone

2.1.4 Psychological Criteria

a) Patient should not suffer from Mental Retardation/ development delayb) The deaf children should have developed adequate social and adjustable

behavior. Stubborn behavior is one of the main contraindication for cochlear implantation.

c) Child may need to be assessed by clinical psychologist in case of suspected abnormal psychological behavior.

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2.2 Pre Implant Counseling By Audiologist

2.2.1 Pre-implant counseling Extensive Pre-implant counseling by the audiologist is very important with regard to the following factors to derive maximum benefit from cochlear implantation.

a) Who would benefit from Cochlear Implantation?b) What exactly the Cochlear Implant does?c) Familiarization with Cochlear implant hardware

a. Internal implant (Explanation through posters and video)b. External Speech processor

d) Choice of External Speech ProcessorWeather to use Behind The Ear or Body Worn speech processor?

e) The patient and parents must be counseled adequately about the advantages and disadvantages in using Behind The Ear or Body Worn speech processor.

f) Particularly the following points must be made clear to them in addition to other points.

g) Who would benefit from Cochlear Implantation?h) Maintenance and running costs. Parents should be made aware of follow-up

expenditure once the mandatory maintenance coverage from the Trust ceases after one year

i) Parents and family should be made aware of how to maintain the delicate apparatus and precautions to be taken in handling the equipment.

j) They should also know cost of spares which are covered under warranty and which are not covered. They should be provided with service numbers and contact person of service center. The company should do the repairs and replacements, if any, without any difficulty to the patient.

l) Do's and Don'ts: Child and parents must be taught the Do's and Don'ts such as:i. Delicate handling of equipment,ii. Proper upkeep of external apparatus,iii. Continuous wearing.iv. Avoiding rough handling and violent jerks to equipment,v. Avoid nudging or acute bending of cables,vi. Keeping the area and apparatus clean,vii. Avoiding oily surface to equipmentviii. Avoid exposure of the processor to moisture and water etc.,

m) Parents / family should be made aware of running costs such as battery replacements etc., and how frequently they are supposed to do it.

n) Realistic expectations to be explained to the patient and parents considering the age at which Cochlear Implantation is done and subsequent long drawn out audio-verbal rehabilitation process.

0) The importance of Audio-Verbal Therapy/ rehabilitation after the implantation should be emphasized with following points

• What is Audio Verbal Therapy?• The role of the mother in Audio Verbal Therapy• How basic communication skills to be developed on the basis of need

based activity and reinforcement process?

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• Parents should be made aware that mere Cochlear Implantation would not develop speech. Speech has to be learnt as done like in any other normal individual.

• Cochlear Implantation act as means to hear all the sounds including speech spoken by others and language and speech have to be learnt. The family should be realistic in expecting the outcome of the Cochlear Implantation considering the age at which it has been done and other Constraints and factors involved.

p) Commitments from the parents, hospital and the patient. The mother should be adequately trained as to how to use the implant and its maintenance.

q) After Cochlear Implantation is done, the whole family should adopt to communicate through speech and no other means.

r) After the cochlear implantation is done there would be online periodical assessment of the implanted child by the committee with regard to the progress after cochlear implantation.

3.0 IMPLANT SPECIFICATIONS

Hospital shall procure standard original implant (and not refurbished) for use under the scheme.

Selection of type of instrument (weather to use Behind The Ear or Body Worn speech processor?).

Hospital shall leave the choice to the beneficiary whether to have BTE processor or Body Worn processor after informed consent, the Network Hospitals shall obtain informed consent from either of the parent duly counter signed by the Surgeon, Audiologist and Aarogyamithra in the given proforma while sending them for screening by the Technical Committee.

The implant should further meet the following minimum basic requirements.

1) Company should provide minimum 5 years warranty2) Hospital audiologist shall provide regular mapping services to the patients.3) Servicing of the implant shall be available in Andhra Pradesh.4) Minimum of 16 Electrode contacts with 8 channels must be available.5) Implant thickness should not be more than 4.2 mm.6) In the rare event of defective and non-performing implant, it should be

replaced with new piece and hospital shall undertake redo surgery free of cost.

4.0 PRE-AUTHORIZATION FORMS AND REPORTS

Network hospital should follow the regular procedure of admission, evaluation and pre-authorization procedures (through the website of the Trust –www.aarogyasri.org) before sending the patient for committee evaluation.

5.0 FREQUENCY OF COMMITTEE MEETING

Committee will meet in the office of the Trust on fixed scheduled dates based on the requirement.

6.0 APPOINTMENT FOR SCREENING

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Based on the number of cases evaluated as per norms and sent for preauthorization by the Network Hospital, an appointment schedule will be given to the hospitals. The Hospital should bring these patients along with both the parents on the scheduled dates without fail. The cost of transportation, food and accommodation (if required) to the patient and parents for evaluation by the committee shall be borne by the Network Hospital.

7.0 CERTIFICATION OF APPROVAL

Based on the assessment, the Committee will give online approval, after which the Trust will approve pre- authorization for hospital to undertake surgery

8.0 HOSPITAL RESPONSIBILITIES Must have requisite infrastructure in the form of both qualified manpower and

proper equipment Shall give adequate pre-implant counseling to both child and parent

Shall arrange for interaction between parents of the patients drafted for surgery with patients and their parents who underwent similar surgery in the same hospital to help proper understanding of the procedure and its benefits

Shall facilitate parents to understand about the availability of different implants and their differences particularly with regards to speech processor.

Shall obtain informed consent from the parent with regards to type of external speech processor (Behind the ear or Body worn) in prescribed proforma

Provide standard implant based on selection of implant by the parent and shall ensure proper follow-up services by the company such as mapping, up gradation, servicing, maintenance and replacement under warranty.

Should cooperate with the inspection team to inspect facilities and medical records and arrange interaction with the beneficiaries admitted in the hospital and during the audio-verbal rehabilitation process as and when required.

Should properly evaluate the patient as per the guidelines given above, before sending the patient for assessment by the committee

Make available all the relevant documents in original along with pre-authorization forms to the committee.

Shall undertake redo surgery in the rare event of implant failure. Arrange for the appearance of the fully evaluated patients along with both the

parents to appear before the committee as per the schedules. Shall arrange for re-counseling to the parents and patient during intervening

period of reevaluation as and when suggested by the Technical Committee in their evaluation certificate.

Hospital shall ensure to provide quality audio verbal rehabilitation services – free of cost, on alternate - day basis to the Cochlear implantees even after the mandatory one year period is over, since most of the children require 3-4 years or more time for the rehabilitation till the child acquires fairly adequate communication skills. Shall undertake to maintain on service the speech processor in terms of disposables (accept batteries) for two years after prescribed time limit under the scheme

9.0 ONLINE SUBMISSION OF BILLS

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The above installments will be released through online transaction on submission of bills after successful completion of each phase of the treatment duly certified by the committee after periodical online evaluation for postoperative events and subject to submission of the following documents

Certification by the Technical Committee Pre-authorization forms with photograph Copy of the Health Card/Ration Card.

Copy of Implant brochure, registration details, warranty card and Maintenance Commitment document from the company. Reports with films Case sheet Copy of discharge summary Post-operative X-Ray

Detailed Bill duly signed by the parents with the registration number of the implant and cost mentioned separately

Patient feed back form Acknowledgement of transport charges.

10.0 SWITCHON AND INITIAL MAPPINGHospital shall upload the following documents while raising claim for Switch on and initial mapping in the follow-up claim module(please see the Trust Portal).

WebEx Video Recording of the switch-on process Photograph Showing child along with external speech processor with label

showing the registration number of the instrument Shall submit the proposed plan of AV Therapy and goals

11.0 AV THERAPY

Hospital shall upload the following documents while raising claim for AV Therapy for each quarter in the follow-up claim module (please see the Trust Portal).

WebEx recording of AV Therapy Session clearly showing the face of the child, parent and AV Rehabilitationist. Progress report of the child AV Rehabilitationist certifying the progress vis-à-vis goals achieved and reasons for failure if child not achieved goals. Parents assessment of progress in online proforma.

12.0 ONLINE WORKFLOWAll the documentation required for the workflow shall be done online at the appropriate time schedules. Hospital may refer the following for guidelines on online workflow.

Online pre-authorization process

Module VIII – E Preauthorization

Rajiv Aarogyasri Manual on Surgical and Medical Treatments for Cashless Treatment of BPL Population (3rd

edition) Page no 243 to 285Initial Mapping and AV therapy

Module XIII – Cochlear implantation – Initial Mapping and Switch on and Audio Verbal Therapy

Rajiv Aarogyasri Manual on Surgical and Medical Treatments for Cashless Treatment of BPL Population (3rd

edition)Page no 355 to 372

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Hospitals may also visit www.aarogyasri.org to view and download the Rajiv Aarogyasri Manual on Surgical & Medical Treatments for Cashless Treatment of BPL Population.

ANNEXURE- XIII

ROLES AND RESPONSIBILITIES OF NETWORK AAROGYAMITHRAS

1. He/She should deal with the patients in a Friendly and Pleasant manner. 2. He/She should be in APRON during duty hours and strictly adhere to duty

timings3. He/She should show patience and empathy while dealing with patients.4. He/She should always keep the CUG switched on round the clock and

should attend to all the Incoming calls politely.5. He/She should bring to the notice of their superiors any irregularity or

inadequacy noticed.6. Maintain Help Desk at Reception of the Hospital. 7. He/She should receive the patients, verify the documents, register them and

direct them to the RAMCO (Rajiv Aarogyasri Medical Coordinator) for further screening and management.

8. Facilitate the patient for a cashless transaction.9. Obtain photograph of the patient - bedside. 10.Facilitate early evaluation and prevent delay in approvals by submitting the

preauthorization complete in all respects.11.Should ensure that patient is on bed from the time pre-authorization request

is sent till the approval is obtained.12.He/She should do regular rounds in the wards and ensure that the patient is

getting all the benefits of the Aarogyasri Scheme.13.Ensure that Hospital is giving free Quality Food to all the beneficiaries who

are In-Patients.14.Facilitate the patient to get the transport charges reimbursed and to

ascertain whether Follow-Up Medicines are served as per the guidelines. 15.At the time of discharge, He/She should take a photo of the patient standing

in front of the Aarogyasri KIOSK besides the Mithras with Discharge Summary in one hand and Transportation amount and slip in the other hand and upload the same in the website.

16.Obtain feed back from the patient. 17.Counsel the patient regarding follow-up. 18.Coordinate with PHC/Government Hospital Aarogyamithra for follow up of

beneficiaries. 19.Coordinate with the Head-Office and Medical officers for any clarifications. 20.He/She should inform the Call-Center immediately in case of a Death and do

send the Death Reports. 21.Send Daily reports as per the formats given by the Head Office to the Call-

Center and to the Hierarchy (Team Leader/Co-coordinator/AAM/AM)

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22.Facilitate Network Hospital in conducting Health Camps as scheduled.23.Facilitate Network Hospital in sending claims online.24.There should be clear communication between Night shift and Day shift

Mithras and Handing over the Duty rooster must be smooth and complete.

25.All Grievances should immediately be brought in to the notice of Grievance Department directly or through Hierarchy.

26.The Mithras should be un-biased while judging the 48 Hrs. deadline given for the patient in furnishing White Card at Aarogyasri Counter to Avail Aarogyasri benefits. He should help the patient and facilitate the need of producing the white card before the Dead-Line.

27.He/She should facilitate the hospital in giving prior phone intimation to the Insurer/trust for carrying out the emergency surgeries.

28.He/She should ensure that all the updating like surgery, post-operative notes and discharge are done in time on the website.

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ANNEXURE -XIV

ROLES AND RESPONSIBILITIES OF RAJIV AAROGYASRI MEDICAL CO-ORDINATOR (RAMCO)

1. He/She will ensure that all required evaluation including diagnostic tests are done free of cost for all beneficiaries and the details of the same along with reports are captured in the Trust portal.

2. He/She will upload the OP/IP status of the patient.

3. He/She will guide the patient in all aspects and sign the investigation request.

4. He/She has to cross check whether diagnosis is covered in the scheme. If doubtful about the plan of management then should coordinate with treating specialist along with Package list as specified in the Rajiv Aarogyasri Manual on Surgical & Medical Treatments for Cashless Treatment of BPL Population.

5. He/She should facilitate the admission process of Patient without any delay.

6. After admission He/She will collect all the necessary investigation reports before sending for approval.

7. He/She will upload the admission notes and preoperative clinical notes of the patient.

8. He/She will ensure that preauthorisation request is sent only for those who are on bed(IP).

9. He/She will ensure before sending Preauthorization that all documents like white card, Patient photo and also necessary reports like CT Films, X-Ray films, Angio CD etc. are uploaded in the system.

10.He/She will upload the admission notes and preoperative clinical notes of the Patient.

11.He/She will coordinate with insurance and trust doctors as need arises.

12.Pre-auth kept pending from Insurance and trust will be verified on a regular basis and necessary corrections to be done by RAMCO.

13.He/She will furnish daily clinical notes (Pre-operative and Post-operative).

14.He/She will upload 3 Photographs of the Patient taken preoperative bedside, immediate post-operative showing operation wound and at the time of discharge.

15.He/She will update surgery and discharge details and hand over signed copy of the summary along with follow-up advice in preprinted stationary supplied.

16.He/She will ensure free follow – up consultations, routine investigations and distribution of drugs to be supplied by the Trust to the beneficiaries.

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17.He/She should attend to the grievances of the Aarogyasri Beneficiaries and Coordinate with the trust if necessary to redresses it within 6 hrs (TAT) through ONLINE MODULE. Further he will counsel the patient accordingly.

18.He/She will ensure at the time of discharge the transportation cost to and fro to be reimbursed to the patient.

19.He/She will upload the operation notes, post operative details and attach necessary post operative documents (like case sheet etc) for claim submission.

20.He/She will ensure that any claim kept pending from insurance for technical or financial reason are be updated immediately.

21.He/She will verify that all documents are submitted in order before sending for claims.

22.Any other responsibility as communicated by the Trust / Insurer.

23.He/She ensure that the surgeries/therapies are performed as per standard Medical protocols of treatment.

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ANNEXURE - XV,

ROLES AND RESPONSIBILITIES OF AAROGYASRI MEDICAL CAMP CO-ORDINATOR (AMCCO)

1. He/She has to Co-ordinate all activities related to Health Camps.2. He/She has to follow up the patients referred from the Health Camps. 3. After receiving Health camp schedule from the Trust, He/She is responsible

for confirmation of camps online and indenting online.4. He/She has to update the details of IEC Activities, Details of Facilities to be

provided in the camp, Details of common drugs to be distributed in the camp and the incentives to be paid to Govt. medical officers with specific proposals and estimated amount at the time of confirming the Health camp.

5. He/She has to follow the Health Camp Policy and Health Camp Work Flow Provided by the Trust.

6. He/She has to start IEC activities at least 7 days before from the camp date.7. He/She has to Mobilize the patients by doing various IEC activities like

pamphlet distribution, mike announcement, advertisements in local daily’s, Dandora, beat of tom-tom, SHG meetings, village meetings, scrolling in local T.V. channels, playing audio visual media etc.

8. He/She has to do Campaigning in surrounding villages of the PHC.9. He/She should provide facilities for patients like shamianas, chairs, pedestal

fans, drinking water, screening enclosures and snacks etc.10. He/She has to provide common medicines in the Health camp.11.Coordinating and ensuring participation of specialists in the Health camp.12.He/She has to arrange diagnostic equipment for the Health camp.13.He/She has to co-ordinate with PHC doctors/govt. doctors, public

representatives and local administration.14.He/She has to distribute the incentives to the medical officers.15.He/She shall speak to the PHC doctor, District Coordinator of the insurer or

District Co-ordinator of the Trust to identify the Medical Officers and Mithras who will participate in the Medical Camp so as to plan and deploy their manpower.

16.After Successful completion of Health camp, AMCCO shall upload and submit Utilization certificate, declaration certificate by PHC medical officer/Aarogyamithra, bills, drug dispensing registers, details of IEC activities, photographs of the camp and IEC activities and receipt of payment of Incentives to the medical officers participating in the camp in prescribed proformas.

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ANNEXURE - XVI

NETWORK HOSPITALS

Do's & Don'ts

Do's

Network Hospitals shall conduct camps with qualified doctors / specialists, equipment , proper awareness and IEC program at the designated location.

The Hospital shall render cash less treatment to all the valid and eligible patient once identified by registering and admitting immediately

To provide space for Kiosk in the reception for Aarogyamithra along with system, network connectivity, printer, scanner, digital camera etc.

Hospital shall evaluate the beneficiaries by conducting free diagnostic tests and counsel the patients who are not covered under the scheme in regard to further management.

To provide a dedicated Rajiv Aarogyasri Medical Coordinator (RAMCO) to co-ordinate and perform an effective role.

Hospital shall provide reasonably good food according to dietary requirement. To provide cost of transportation. To provide free follow-up for beneficiaries according to provisions in the package The hospital should submit the claim only after 10 days of discharge. The hospital should appoint dedicated Aarogyasri Medical Camp Coordinator to

coordinate camp related activities. Network hospital should attend the periodical training workshops / programmes

organised by Aarogyasri Health Care Trust/Insurance Company. To utilize the Rajiv aarogyasri manual on Surgical & Medical Treatments for

cashless Treatment of BPL Population provided by the trust to the best possible extent for proper understanding of the scheme.

Hospitals to send proper pre-authorization and resubmit pre-authorizations kept pending after thorough scrutiny and only after uploading the required documents / reports to avoid delay in clearance.

To update the details of on bed status of patients time to time as per the format (Refer annexure XX) on the display board placed at the Aarogyamithra Kiosk / reception desk.

Respond to the Grievances registered against the hospital and resolve/redress within the TAT and submit through ONLINE Grievance Module.

Don'ts× Don’t collect money from patients who are identified as beneficiaries under

the scheme for any consultation , diagnosis or treatment. × Don’t take possession of any original document from the patient at any point

of time.× Don’t charge from the patient in any form as the package includes the entire

cost of treatment from date of reporting to the time of discharge and 10 days of discharge

× Don’t send patients home during the waiting period (for pre authorisation approval)

× Don’t send for pre authorization approval in duplicate.× Don’t misuse Telephonic intimation for approval for non-emergency cases.

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× Don’t update Operation notes and Discharge summary in cases where surgery is not performed.

× Don’t apply for multiple procedures in the same patient without clinical justification.

× Don’t submit pre-authorization approval repeatedly for the same patient.× Don’t send patient or attendants to Trust / Insurance office for approval and

enhancement. It has to be done by the hospital with the help of preauthorization and enhancement module.

× Don’t submit wrong Telephone numbers of treating specialist in the column provided. This may delay the approval of pre authorization.

× Don’t submit clinical photograph, which is incomplete and inconclusive. The postoperative photograph should reveal as much as possible the operative site and the patients face.

× Don’t collect any amount towards follow-up consultation & medicines in cases where follow-up packages are provided, as the services are inherent with the pre-defined package.

× Don’t collect money from patients / family to procure blood / blood products but facilitate to procure in case it is not available within the hospital blood bank except in case of hematological disorders.

× Don’t recruit ex-employees of insurer anytime during this agreement and also for a further period of one year from the date of expiry of this agreement.

× Don’t submit false claims with manipulated evidences.

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ANNEXURE-XVII

1. Selection of procedure in case of Triple Vessel Disease (TVD) (whether CABG or Angioplasty)

Whenever a treating doctor decides to perform angioplasty for Triple Vessel Disease instead of CABG, either due to associated conditions or due to patient’s choice of selection after being counseled about the advantages and disadvantages of both the procedures, the following evidence shall be uploaded for approval.

(i) The detailed explanation letter by the treating doctor for opting for angioplasty procedure.

(ii) A consent letter from the patient stating that the procedure was of his choice and decision was taken after due counseling by the treating cardiologist and cardio thorasic surgeon.

(iii) The consent letter must be duly signed by the treating cardiologist and cardio thorasic surgeon.

2. Additional objective assessment required in case of moderate stenosis(<70%)

In cases of moderate stenosis (<70%) where the role of angioplasty is doubtful as perceived by the pre-authorization specialist, the hospital shall submit the following additional objective assessment of Ischemia.

(i) Treadmill Test and/or (ii) Thallium study

Further Insurance Co. may obtain second opinion from senior cardiologist. These may be required either alone or in combination as case requires.

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ANNEXURE -XVIII

Rajiv Aarogyasri Community Health Insurance Scheme

Undertaking to provide Infrastructure

We hereby agree and undertake to provide the following infrastructure and network facility to the counter: P.C, Printer, Scanner, Digital camera, Webcam, Barcode reader, Mike, Speakers, Min. 2MBPS Broadband Net -connection, Stationary etc., which shall be exclusively for the use of Aarogyamithra from our end to ensure the smooth operation.

Seal Signature of Hospital CEO /MD/Superintendant.

Date: Place

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Annexure - XIX

Rajiv Aarogyasri Community Health Insurance Scheme

Core Banking Number - IFSC code

We__________________________________ (Hospital) hereby declare that we have the core banking facility with the ________________________________________Bank (mention the name of the Bank having Branch at _______________________________ .

The IFSC No. _______________________ (Mention your core banking Number)

Signature of CEO/MD/Authorized Signatory.

In case of non availability of IFSC Code

I agree to provide the IFSC number within Five (5) working days on receipt

of this information.

Seal Signature of CEO/MD/Authorized signatory.

Date: Place

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ANNEXURE - XX

The Network hospital shall display the status of Total No. of Beds in the Hospital, total No. of Beds under Aarogyasri community Health Insurance scheme and also display the No. of Beds occupied by the Aarogyasri patients specialty wise on a White Board with Black Letters. The Network Hospital shall update the Board from time to time in the following format placed at the reception/admission desk:

Rajiv Aarogyasri Community Health Insurance Scheme

Date:

Time:

Name of the Hospital:

Total Bed status in the Hospital

Total No. of Beds in the Hospital:

Total No. of Beds Occupied:

No. of Beds under Rajiv Aarogyasri Scheme:

No. of Beds occupied by Aarogyasri patients:

No. of Beds available:

Specialties empanelled under Rajiv Aarogyasri Scheme:

Specialty wise status of Beds in the Hospital

Specialty Name:

Total No. of Beds in the Hospital:

Total No. of Beds Occupied:

No. of Beds under Rajiv Aarogyasri Scheme:

No. of Beds occupied by Aarogyasri patients:

No. of Beds available:

Signature of RAMCO

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ANNEXURE – XXI

GUIDELINES FOR ENHANCEMENT OF PACKAGES

I. CASES ELIGIBLE FOR CONSIDERATION OF ENHANCEMENT

1. There is a need for additional surgical procedure/Treatment, which is not covered under Aarogyasri scheme in addition to the procedures/Treatment approved under the scheme.

2. The procedure is extended due to underlying (Anatomical, Pathological etc.,) variances in the patient.

3. Complications totally unrelated to the surgical procedure and due to underlying associated conditions such as:

a. Diabetes

b. Hypertension

c. Immunosuppressive status etc

And for which there is no alternative package available in the present scheme.

4. Medical/Surgical Complications for which packages are available but totally unrelated to the approved Surgery/Therapy for which the hospital cannot be empanelled due to infrastructure requirements. In all such cases enhancement amount shall be equal to the approved package amount under the scheme.

5. HIV, HbsAg or HCV positive patient requiring additional inputs for approved surgery/therapy under the scheme.

6. For associated injuries in poly-trauma for which no package is available in the scheme.

7. Complications in cases of Medical / Conservative Management for which packages are not available under the scheme leading to extended hospital stay (see timing of request).

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II. EVIDENCE TO BE SUBMITTED BY THE HOSPITAL FOR THE ENHANCEMENT CASES

1. Detailed evidence of diagnostic tests along with details of procedure /Treatment contemplated/ done recorded in operation notes/clinical notes and /or with video graphic evidence.

2. Details of procedure/Treatment to be recorded in operation notes/clinical notes along with explanation by the treating doctor and /or with video graphic evidence.

3. Details of complications and underlying associated condition with the diagnostic support (Biochemical/Pathological/Imageological evidence).

4. Detailed evidence of diagnostic tests along with procedure /Treatment contemplated/ done recorded in operation notes/clinical notes and /or with video graphic evidence .

5. Diagnostic support for HIV, HbsAg or HCV

i. At least two reports; one test specific to the condition shall be positive and shall be from the lab other than attached to the hospital to be made available.

ii. In case of HIV, Report from nearest VCTC center may be desirable.

6. Details of injuries to be recorded in pre-auth/clinical notes along with photographic evidence.

7. Details of complications and treatment details to be recorded in pre-auth/clinical notes along with the diagnostic support (Biochemical/Pathological/Imageological evidence). And copy of case sheet shall be attached in support of above.

III. TIMING OF THE REQUEST

1. Enhancement in case of medical packages or conservative managements shall be entertained only after completion of the twice the indicated period of the Hospital stay (As per the package) or a minimum of one month whichever is more but before the Discharge of the patient.

2. For surgical procedures immediately after updating of operation notes for additional procedures /variances but before discharge.

3. For complications unrelated to surgical procedures the request shall be after the treatment of complication and before discharge.

IV. GUIDELINES FOR CALCULATION OF ENHANCEMENT AMOUNT

The enhancement amount may be based on the following calculations:

a. No. of days of hospitalization.

b. No of days in ICCU stays.

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c. No of days in ICCU stays with ventilator.

d. The type of drugs used which are essential for recovery of the patient.

e. Relevance of such procedure/treatment.

f. Type of additional/associated procedure done.

g. Type of medical complication.

h. Outcome of the Procedure/Treatment.

The total amount approved will be within the overall ceiling of Rs.2 lakhs per family in a year.

V. UPDATING THE DATA ONLINE

1. The hospital shall upload the entire relevant data necessitating enhancement such as diagnostic tests, clinical photographs/video recording, bills, consultant notes, present status of the patient and clarification letter by specialist if any. In case of burns the hospital shall upload the clinical photographs of the patient clearly depicting the treated area and raw areas yet to be covered. And photographs of injuries in case of trauma.

2. Declaration by the patient/attendant that the treatment is being extended on cashless basis.

VI. CASES FOR REJECTION

1. Any request of enhancement merely on the ground that total treatment cost exceeded the package amount or hospital stay is exceeded the indicative stay.

2. Subsequent requests for the enhancement after being approved once.

3. The procedure /Treatment is unwarranted, not in conformity with laid down standard medical protocols and does not help in outcome of the case

4. Early submission of request

5.Submission of request after discharge.

6.Mere presumption of case may get into complications due to high risk.

7.Common post-operative complications, complications directly attributed to primary ailment for which pre-authorization was obtained. The hospital shall extend cashless treatment to these complications under the package only as explained in package guidelines.

8. Any delay in submitting the relevant data for more than 48 hours after opening the key is liable for rejection by the “Technical committee”.

The hospital shall extend the cashless treatment & services to the Aarogyasri patients under the approved package irrespective of the status of the enhancement and shall be treated till the patient is fit for discharge. The opinion of the Technical

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committee with regard to enhancement of the package and the amount approved or rejected will be the final and binding on the hospital (Refer to clause No: 16.1&17.1of MoU) and no further representations in this regard will be entertained by the Insurance Company / Trust.

VII. PROCESS FLOW OF APPROVALS

• Hospital will mail/fax the request with relevant medical data to the Trust through enhancement @aarogyasri.org.

• The request will be preliminarily processed by the JEO (Technical) and may reject if found not in accordance with the guidelines.

• If the request is found in accordance with the guidelines for enhancement, Enhancement Key will be opened and Hospital will be enabled to upload documents online and send online request in pre-authorization flow.

• Simultaneously the request will be placed in front of Technical Committee with the data available for its assessment and recommendation.

• Incomplete data may lead to pendency and hospital will be requested to provide the same through all possible communications. Failure on part of hospital to attend to the pendency request for more than 48 hrs may lead to rejection of request.

• The committee recommendation will be placed in front of CEO of Aarogyasri Health Care Trust for final approval.

• Then the online approval will be given for the enhancement of package, duly uploading the certificate of approval within the overall ceiling of Rs.2 Lakhs per family in a year.

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Annexure XXII

I/we hereby declare that our hospital is empanelled with multiple specialties and accordingly we nominated RAMCO’s. The names o f the RAMCO’s are listed below.

Sl.No Name of the RAMCO

Qualification Registration Number

University Mobile Number

Experience Photograph of RAMCO

Signature

We hereby declare that the login user ID’s provided to the RAMCO’s will not be misused and the login user ID’s provided will be exclusively used by the respective RAMCO and will not be shared with any other person to protect the sanctity of the scheme. And declare that the _____________ hospital will be held responsible for any misuse of the Login ID’s and are liable for penalization as per prevailing Criminal & Cyber Laws.

Signature of RAMCO Signature of CEO/MD/Superintendant

Seal Seal

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Annexure XXIII

I/we hereby declare that our hospital is nominated ______employees in order to process the online workflow. The details of the employees are listed below.

Sl.No Name of Billing Head

Qualification Designation Mobile Number

Photograph of Billing Head

Signature

We hereby declare that the login user ID’s provided to the billing head will not be misused and the login user ID’s provided will be exclusively used by the respective billing head and will not be shared with any other person to protect the sanctity of the scheme. And declare that the _____________hospital will be held responsible for any misuse of the Login ID’s and are liable for penalization as per prevailing Criminal & Cyber Laws.

Signature of RAMCO Signature CEO/MD/Superintendant

Seal Seal

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Annexure XXIV

I/we hereby declare that our hospital is employed/Nominated ______AMCCO’s in order to process the online workflow. The details of the employees are listed below.

Sl.No Name of AMCCO

Qualification Designation Mobile Number

Photograph of employee

Signature

We hereby declare that the login user ID’s provided to the AMCCO will not be misused and the login user ID’s provided will be exclusively used by the respective AMCCO’s and will not be shared with any other person to protect the sanctity of the scheme. And also declare that the _____________hospital & AAMCO will be held responsible for any misuse of the Login ID’s and are liable for penalization as per prevailing Criminal & Cyber Laws.

Signature of RAMCO Signature of CEO/MD/Suoperintendant.

Seal Seal

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Annexure XXV

Data Entry Operators working under RAMCO

Sl.No Name of Data Entry Operator

Qualification Designation Mobile Number

Photograph of Employee

SignatureOf Data Entry Operator

Name of RAMCO assigned

Signature of RAMCO

I/we hereby declare that our hospital has employed/nominated data entry operators as mentioned above, each data entry operator will be linked to respective RAMCO assigned above and the final responsibility for the data fed by the data entry operator will be vested on RAMCO and Hospital. And also declare that the Hospital & RAMCO will be held responsible for manipulation of data and liable for penalization as per prevailing Criminal & Cyber Laws.

Signature of RAMCO Signature of CEO/MD/Superintendant.

Seal Seal

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Annexure – XXVI

Tax Deduction at Source To

The General Manager-ClaimsStar Health And Allied Insurance Co.Ltd

Rajiv Aarogyasri community Health Insurance Scheme

Data of Hospitals for Deduction of TDS from Claims payment.

1. Name of the Hospital :2. Address :

3. Constitution : Sole Proprietorship /Partnership/Private Limited company / Public Limited Company /AOP Regard Public charitable Trust/ Any Other entity (please specify)……………………..

(Strike whichever is not applicable)4. Name of the Owner/Managing Partner/ Director /Trustee/Authorized Person :5. Income Tax PAN : (Copy of PAN card be enclosed)6. If certificate for TDS Exemption / lower rate Deduction obtained from Income Tax, details there of : (Copy of letter from IT to be attached)7. IT returns filed up to :8. Name & address of Auditors : With contact No.9. Name of Contact Person with : Mobile No. & email id.

Authorized signatory. Seal of the Hospital

NOTE: If the hospital is having exemption certificate issued under sec 197 of Income Tax act by Jurisdictional Assessing Officer applicable ie., RANGE-14 & RANGE 15 stationed at Hyderabad,RANGE-3 Vijayawada, RANGE-6 Vishakapatnam and RANGE-3 Tirupathi under the jurisdiction of Commissioner of Income Tax (TDS), Hyderabad (Refer Aarogyasri Health Care Trust circular No.1265/F-32/2009-10, dt:19-03-2010), the same may be submitted. Further it is to be noted that Non-deduction of tax will effected upto the expiry date of Exemption certificate produced.

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Annexure –XXVII

Emergency Telephonic Intimation - Instructions to Network Hospitals

As you are aware Rajiv Aarogyasri scheme aims at providing treatment for life saving diseases/procedures and emergency cases in addition to elective cases. In order to ensure that the Aarogyasri beneficiary get timely treatment we are here by communicating the process of Telephonic intimations. To facilitate emergency telephonic intimations Network Hospitals are required to follow the procedure given below.

(i) The person calling from Network hospital can be RAMCO / Treating doctor / Duty doctor who can furnish minimum details of the patient and clinical findings. We will facilitate the caller if there is any ambiguity regarding coverage of the procedure or treatment in the scheme.

(ii) Contact numbers for emergency Telephonic approvals for both AS1 & AS2

1. 9490165211 2. 9490155446

3. 9490155441 4. 9490720832

(iii) Once the call is received the workflow given below will be followed

(iv) In order to continue with the workflow, Network Hospital has to send the Preauthorization within 72hrs through emergency telephonic intimation ID, otherwise

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the emergency approval will be cancelled automatically in the system and the status of the Telephonic intimation will change to ‘Telephonic Intimation cancelled’

ANNEXURE -XXVIII

GUIDELINES FOR ENT SURGERIES

1. TYMPANOPLASTY

1. The ideal age for Tympanoplasty is between 15yrs and 60yrs.2. In Tympanoplasty Surgery the Operation notes should mention about the

Ossicular Status (and its mobility per operatively) and the Ossicular reconstruction is to be planned and performed if necessary if Hearing Costs is more than 50db preoperatively. Unless it is done for the required Cases the Claim will not be approved.

3. For Tympanoplasty the Post OP PTA has to be done 3weeks after Surgery with Post OP Otoendoscopy photos showing the graft in place and Claim has to be submitted 3 weeks after surgery not before.

4. If any Surgeon wants to do Tympanoplasty in Children below 15 years, the counseling form should be filled and signed by the Parents of the child and by the Surgeon. (Annexure-I )

5. A declaration in the prescribed proforma should be furnished by the Treating Surgeon for performing Tympanoplasty surgery in the children below 15 years of age. (Annexure-II )

6. In case of failure of Tympanoplasty the Surgeon has to redo it free of cost. The Aarogyasri Trust will not sanction money for such failures in less than 3 months after surgery.

2. MASTOIDECTOMY:

CT. Scan of temporal bones is not required for Mastoidectomy.

3. STAPEDECTOMY + VEIN GRAFT:

CT. Scan of temporal bones is not required for Stapes Surgery.

4. ENDOSCOPIC DCR SURGERY (S2.3.7):

For Diagnosis of Chronic Dacryocystitis for Endo DCR Surgery, a certificate from the Ophthalmologist is a must.

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5. MICROLARYNGEAL SURGERY:

In case of surgery for multiple juvenile Papillomatosis, the 2nd and 3rd time for recurrence is approved with a gap of 6 months and the Pre-Op-Photos (VLS), In Per OP (MLS) & Post OP Photos of VLS to be uploaded every time it is submitted for surgery for recurrence of disease.

6. BEHIND EAR ANALOGUE HEARING AID (S16.3.1):

For Deaf-mutes’ children with sensory Hearing Loss before 12 years of age the BHE Hearing Aid is to be prescribed before sending children for cochlear Implant Surgery and Rs. 10,000/- is approved.

Whenever the Surgeries under ENT are planned the following evidence shall be uploaded for approval.

i) Counseling Form for Tympanoplasty in children less than 15 years of age duly signed by the Treating Doctor and Parents of the patient.

ii) The Consent Letter duly signed by the Parents of the patient and Treating Doctor

iii) Declaration by the Surgeon for performing Tympanoplasty surgery in the children below 15 years of age.

All the Network Hospitals are requested to note these guidelines in selecting the cases to avoid the rejections and inconvenience to the patients.

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Annexure – XXIX

NAME OF THE HOSPITAL:

DISTRICT : PATIENT DEATH REPORT

BENEFICIARY DETAILS

1 WAP NO

2 NAME OF THE BENEFICIARY

3 AGE

4 GENDER

5 COMMUNICATION ADDRESS

6 MANDAL

7 DISTRICT

8 CATEGORY

9 SURGERY / THERAPY

10 HOSPITAL NAME

11 DATE OF ADMISSION

12 CLAIM NO.

13 DATE OF SURGERY

14 DATE OF DISCHARGE

15 DATE OF DEATH

16 REASON FOR DEATH

17 DEATH CERFICATE NO

THE DETIALS FURNISHED BELOW ARE BEST OF MY KNOWLEDGE

NAME OF THE PERSON

AGE

GENDER

COMMUNICATION ADDRESS / CONTACT NO.

RELATIONSHIP WITH EXPIRED PERSON

SIGNATURE / THUMB IMPRESSION

Date: Signature: Treating Doctor

Seal of the hospital

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Signature: RAMCO / MEDICAL SUPERINTENDANT

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