Term No.
Subject
Page No.
TERMS OF THE SCHEME
General
1
Definitions
Fund Details
2
Salient features
3
Benefit coverage
4
Policy and Contribution
5
Period
6
Empanelment
7
Disciplinary actions
8
Medical Audit
9
NWH Requirements
10
Obligations of NWH
Pre-authorisation and Claims
11
Pre-authroisation
12
Claims
Implementation Process
13
Patient process flow
14
Trust office functions
15
Field operations
16
Web portal and online workflow
17
Project Monitoring – Implementation Committees – State and District
18
Packages
19
Follow-up packages
THE SCHEME DATA (TSD)
2
Salient features
3
Coverage
4
Policy and Contribution
5
Period
6
Empanelment
STAFFING
Staff requirement
Eligibility criteria
Annexure-1
Annexure-2
A.TERMS OF THE SCHEME
Term No.1
Term Heading: DEFINITIONS
SUBTERM NO.1
In this document, the following terms shall be interpreted as indicated below.
(a) General Definitions
(i)  “Applicable Law” means the laws and other instruments having the force of law in India.
(ii) “Benefit” shall mean the extent or degree of service the  beneficiaries are entitled to receive based on tailor made policy.
(iii) “Beneficiary” shall mean all the eligible employees and pensioners along with their family members.
(iv)  “Employees” shall mean all the employees working under State Government and identified by the Finance Dept.
(v) “Claim Float” shall mean the money made available to the scheme by the Trust to meet the claims.
(vi) “Claim Float Account” shall mean the bank account where  the claim float is parked and replenished on agreed terms by the Trust.
(vii) “Co-morbid conditions” shall mean all the associated diseases being suffered by the patient in addition to the disease among listed therapy.
(viii) “Coverage” shall mean the entitlement by the beneficiary to Health Services provided under the Policy, subject to the terms, conditions, of the policy.
(ix)  “Family” shall mean all the dependent members of the employees and pensioners as provided by the Finance Dept.
(x) “Government” means the Government of Andhra Pradesh or the Government of India.
(xi) “Government Authority” shall mean either GoAP or GoI or Aarogyasri Health Care Trust (AHCT) or any entity exercising executive, legislative, judicial, regulatory or administrative functions of or pertaining to Government and having jurisdiction over the Company, the parties, any shareholder or the assets or operations of any of the foregoing including but not limited to the Insurance Regulatory and Development Authority.
(xii)  “Law” includes all statutes, enactments, acts of legislature,  laws, ordinances, rules, bye-laws, regulations, notifications, guidelines, policies, directions, directives, and orders of any Government, Government Authority, Court, Tribunal, Board or recognized stock exchange of India, as may be applicable to the Scope and Terms of this Agreement.
(xiii) “Pensioners” shall mean all the retired employees of state Government receiving pension. The detailed list as provided by the Finance Dept.
(xiv) “The Scheme” means the description of services including the disease and financial coverage, the terms and conditions of services as given in volume-1.
(xv) “TOS” means Terms of the Scheme.
(xvi) “TSD” means The Scheme Data.
(xvii) “Eligibility Card” shall mean Health Card issued by the Trust based on the information provided by the Finance Department and data of the civil supplies department.
(b)  Entities
(i) “Network Hospital” or “NWH” shall mean the hospital, nursing home or such other medical aid provider empanelled with the Trust duly following the empanelment procedure of the Trust.
(ii) “PNWH” means Private Network Hospital.
(iii) “Party” means the Purchaser or the Supplier, as the case 
              may be; and “Parties” means both of them.
(iv) “Purchaser” means Aarogyasri Health Care Trust.
(v) “Third Party” means any person or entity other than the Government, the Trust, the Service Providers or a Subcontractor.
(vi) “Trust” means Aarogyasri Health Care Trust of Government of Andhra Pradesh.
(c)   Scope
(i) “Budget” means the amount that is allocated by the Trust for the purpose of funding the scheme during the contract period.
(ii) “Category” means the groups of therapies as mentioned in the scheme.  For example, Poly trauma, Cardiology, General Surgery etc., are categories under the scheme.
(iii) “Confidential Information” means all information (whether in written, oral, electronic or other format) that have been identified or marked confidential at the time of disclosure including Project Data which relates to the technical, financial and business affairs, customers, suppliers, products, developments, operations, processes, data, trade secrets, design rights, know-how and personnel of each Party and its affiliates which is disclosed to or otherwise learned by the other Party whether a Party to this Agreement or to the Project Agreement in the course of or in connection with this Agreement (including without limitation such information received during negotiations, location visits and meetings in connection with this Agreement or to the Project Agreement).
(iv) “Deliverables” means the products, infrastructure and services specifically developed for “Aarogyasri Health Care Trust” and agreed to be delivered by the Service Provider in pursuance of the agreement and includes all documents related to the service, user manuals, technical manuals, design, methodologies, process and operating manuals, service mechanisms, policies and guidelines, and all their modifications.
(v) “Goods” means all equipment, machinery, furnishings, Materials, and other tangible items that the Supplier is required to supply or supply and install under the Contract, including, without limitation, the Information Technologies and Materials, but excluding the Supplier’s Equipment.
(vi) “Health Services” shall mean the health care services and supplies covered under the Policy.
(vii) “Hospitalization Services” shall have the meaning ascribed to it for all treatments and other services of network hospital as defined in the scheme.
(viii) “Listed Therapies” means the list of surgeries, procedures and medical treatments mentioned in the scheme.
(ix) “Package” shall be as defined in Term-19.
(x) “Package Price” means the price paid for the package to a NWH.
(xi) “Proprietary Information” means processes, methodologies and technical, financial and business information, including drawings, design prototypes, designs, formulae, flow charts, data, computer database and computer programs already owned by, or granted by third Parties to a Party hereto prior to its being made available under this Agreement, Project Agreement or a Project Engagement Definition.
(xii) “Services” shall mean all medical health care and ancillary services agreed to be made available by the TPA to the insurer and or the Policy Holders and or the Insured Persons.
(xiii) “Service Area” shall mean the area within which insurer or TPA is authorized to provide services.
(xiv) “Service Level” means the level and quality of service and other performance criteria which will apply to the Services as set out in any Project Agreement.
(xv) “Software” is a collection of computer programs and related data that provide the instructions for telling a computer what to do and how to do it.
(xvi) "Materials" means all documentation in printed or printable form and all instructional and informational aides in any form (including audio, video, and text) and on any medium, provided to the purchaser under the Contract
(xvii) “Intellectual Property Rights” means any and all copyright, moral rights, trademark, patent, and other intellectual and proprietary rights, title and interests worldwide, whether vested, contingent, or future, including without limitation all economic rights and all exclusive rights to reproduce, fix, adapt, modify, translate, create derivative works from, extract or re-utilize data from, manufacture, introduce into circulation, publish, distribute, sell, license, sublicense, transfer, rent, lease, transmit or provide access electronically, broadcast, display, enter into computer memory, or otherwise use any portion or copy, in whole or in part, in any form, directly or indirectly, or to authorize or assign others to do so.
(d)   Place and time
(i)  “Project office” means the office established by Trust as defined at Term No. 14.
(ii) “Hour” means the hour as appearing in 24 hour format (hh:mm).
(iii) “Day” means calendar day of the English Calendar.
(iv) “Week” means seven (7) consecutive Days, beginning     Monday.
(v) “Month” means calendar month of the English    Calendar.
  (vi) “Year” means twelve (12) consecutive Months.
      (vii) “Effective Date” shall be as defined in the contract.
     (viii) “Contract Period” is the time period during which this              Contract governs the relations and obligations of the                 Purchaser and Supplier in relation to the Work, as specified in the SCC.

Fund Details
Term No.
2
Term Heading
Salient Features
Sub Term No.
.1
Name
The name of the scheme is Employees and Pensioners Healthcare Fund.
.2
Objective
To provide cashless treatment to the employees and pensioners along with their families through the network of empanelled hospitals of the Trust. 
.3
Beneficiaries
The Scheme is intended to benefit all the employees and pensioners along with their families as specified in TSD.  The department wise breakup is given in TSD.  The family members will be as defined by the Government (see TSD for details).
.4
Eligibility Definition
All employees and pensioners of the state of Andhra Pradesh, as defined by Finance Department of Government of Andhra Pradesh along with their families as defined by the civil supplies department, shall be eligible under this scheme.
Eligibility card:
The eligible families will be provided with health cards by the Trust based on the aforementioned data, herein after called eligibility cards.  The process of issue of health card is as given in TSD.
Eligibility card for this scheme means:
Health card issued based on the data of finance department seeded with the family details from civil supplies department.
Eligibility verification:
The eligibility of beneficiary under the scheme shall be verified using Aarogyasri IT application or through any other means as decided by the Trust.  The process of verification before issue of health card is as given in TSD.
.5
Excluded beneficiaries
Such of the beneficiaries, who are covered for the “listed therapies” by other insurance schemes such as CGHS, ESIS, Railways, RTC, Arogya Bhadrata of Police department etc., shall not be eligible for any benefit under this scheme.
.6
Family
 (a) In case of male Government Servant, family means his parents, wife, legitimate children including an adopted son and step children residing with and wholly dependent on him;
                   i) The word “wife” includes more than one wife.
ii) A married daughter who is under the protection of her husband does not come within the definition of “family “for the purpose of the scheme.
iii) The deserted, divorced or widowed daughters who are residing with entirely dependent on the Government Servant.
iv) Family includes adoptive parents who are wholly dependent on the Government Servant but does not include the real parents, though they are wholly dependent on the Government Servant once the adoption is affected.
(b) In case of female Government Servant it means her parents, husband and children residing with and holly dependent on her.
.7
Enrolment process
Finance department will provide the details of each eligible employee or pensioner covered under the scheme along with the details of eligible family members if available.  In case the details of family members are unavailable the data will be obtained from the ration card data from civil supplies department.  The Trust will issue health card based on this data.  This eligibility card shall be considered as the result of an enrolment and identification process for availing the benefit under the scheme. The databases of the finance department and Civil Supplies Department of Govt. of Andhra Pradesh shall be the only basis for determining the eligibility.
.8
(a) Coverage limit
 The scheme shall provide coverage for the services to the beneficiaries up to the amount specified in TSD.
(b) Floater Basis
The coverage limit on a beneficiary family shall be on floater basis.  The beneficiary family shall have the ability to avail of the total coverage limit either individually by one member or collectively by two or more members of the family.
.9
Buffer Sum 
    An additional sum shall be provided as Buffer (also referred as corporate floater) in case the cost of services to the beneficiary family exceeds the coverage limit. The buffer shall also be utilized on floater basis. The amount of buffer shall be as specified in TSD.  The buffer utilization shall be authorized by the CEO or his designee.
.10
Deductible
There shall be no deductible under this scheme.
.11
Co-payment
There shall be no co-payment under this scheme.
.12
Pre-authorisation
The prior authorization shall be as specified at Term 11.

Term No.
3
Term Heading
Benefit Coverage
Sub Term No.
.1
Out-Patient
The list of outpatient treatments under the scheme shall be as specified in TSD.
.2
In-patient
(a) The scheme shall provide coverage for the “Listed Therapies”     for identified diseases in the categories as specified in TSD.
(b) Detailed list of “Listed Therapies” falling in the identified      categories and packages is given at TSD.
.3
Pre-existing diseases
All diseases under the proposed scheme shall be covered from day one.  A person suffering from any disease prior to the inception of the policy shall also be covered.
.4
Pre and Post hospitalisation requirement
From date of reporting to hospital up to 10 days from the date of discharge from the hospital shall be part of the package rates.
.5
Follow-up Services
Network Hospitals will provide free follow-up services to the     patients under follow-up packages as specified in TSD.
Term No.
4
Term Heading
Policy period and Contribution
Sub Term No.
.1
The Trust has estimated an amount as specified in TSD as budget.
.2
Policy
The Trust will issue a tailor-made policy covering the entire risk of beneficiaries under the scheme to the Government.
.3
Payment of contribution
The beneficiaries shall pay monthly contribution to the Trust as specified in TSD.
.4
Scheme experience
The scheme is designed based on the disease profile of employees given by the medical department and the experience of Aarogyasri over the last 4 years.
.5
Administrative cost
The admissible administrative cost ceiling under the scheme shall be 5%. Any administrative charges in excess of the admissible administrative costs shall not be allowed.

Term No.
5
Term Heading
Period
Sub Term No.
.1
Period of Coverage
The initial period of coverage under the scheme shall be three years.  The subsequent coverage under the scheme shall be decided after the expiry of three years.
.2
Period of contract
The insurance coverage under the scheme shall be in force for the period of three years.
.3
Run-off period
A “Run Off period” of one month shall be allowed after the expiry of the policy period. This means that pre-authorisations can be done till the end of policy period and surgeries for such pre-authorisations can be done up to one month after the expiry of policy period and all such claims shall be honoured.

Empanelment and Disciplinary Action
Term No.
6
Term Heading
Empanelment
Sub Term No.
.1
Health Care Providers
A health care provider shall be a hospital or nursing home in Andhra Pradesh established for indoor medical care and treatment of disease and injuries and should be registered under Andhra Pradesh Private Allopathic Medical Establishments (Registration & Regulation) Act and Pre-Conception and Pre-Natal Diagnostic Techniques Act (Wherever Applicable). 
A health care provider who fulfils the empanelment criteria of the Trust as specified in Term 9, shall become eligible for empanelment with the Trust. An empanelled health care provider shall be referred as a network hospital. The number of network hospitals as on date is as specified in TSD.
.2
Empanelment and Disciplinary Committee (EDC)
The committee shall regulate the NWH services.
.3
(a) EDC functions
Empanelment and Disciplinary Committee (EDC) under the  chairmanship of Chief Medical Auditor of the Trust shall be responsible for
(i) Empanelment of new hospitals,
(ii) Regulation of empanelled hospitals,
(iii) Disciplinary actions, and
(iv) Settlement of disputes regarding claims. 
(b) Empanelment
EDC shall ensure that a hospital possesses adequate infrastructure, man power, equipment requirements of the Trust, and conforms to the service and quality standards of the Trust.
The empanelment process followed by the Trust includes online 
procedures.
.4
Distribution and requirement of NWH
Hospitals will be empanelled across the state (currently 350 in number) and those hospitals outside the state which are NABH accredited.
A 50 bedded hospital intending to get empanelled is expected to have one or more specialities of General Surgery, Orthopaedics, OBG, Paediatrics, General Medicine, ENT, and Ophthalmology among the basic specialities.
A multi speciality hospital desirous of empanelment is expected to have facilities for one or more super speciality services such as Cardiology and CT Surgery, Medical and Surgical Gastroenterology, Paediatric surgery, Plastic surgery, Neurology and Neurosurgery, Nephrology and Urology among the super specialities.
.5
Empanelment process
The existing process in the trust shall be followed.
.6
Single agreement between Trust and NWH
The agreement between the Trust and NWH shall provide for payments under the scheme to the NWHs as per the “package prices” for the “listed therapies”. 
Term No.
7
Term Heading
Disciplinary action
Sub Term No.
.1
Reasons for disciplinary action
 The EDC shall initiate disciplinary proceedings against erring NWHs for the following reasons:
(i) Infrastructure deficiencies
(ii) Equipment deficiencies
(iii) Man power deficiencies
(iv) Service deficiencies
(v) Violation of service contract agreement
.2
Disciplinary action
Based on the assessment of deficiencies, the EDC shall have the powers to recommend one or more of the following disciplinary actions:
(i) Withholding of payments: Cashlessness is the bedrock and the primary non-negotiable of this scheme. Any violation of this condition shall result in immediate withholding of entire payments of the hospital. Payments shall be released only after the hospital repays the patient and takes corrective measures.
A particular claim may also be withheld in case of any service deficiency in management of any case and the payment may be released based on the expert opinion obtained by the Trust or after rectification. 
(ii) Levy of penalty: In cases where all the payments have been released to the NWHs, a penalty shall be levied on the NWH for violations attracting action at Term 7.2 (i).
(iii) Suspension: The NWH shall be liable to be suspended in all cases of violations of agreement.
 (iv) De-empanelment of specialities: The NWH shall be de-empanelled for a particular speciality in case of service deficiencies.
  (v) Delisting: The NWH shall be delisted for repeated violation of service contract agreement and other service deficiencies for a period of not less than six months.

Term No.
8
Term Heading
Medical Audit
Sub Term No.
.1
Medical Audit
The success of the scheme rests on ensuring that all the stakeholders adhere to the highest level of medical ethics. Chief Medical Auditor shall be performing the following medical audit functions:
(i)   Monitoring of quality of medical care.
(ii)  Framing guidelines to prevent moral hazard.
(iii) Monitoring the trends of utilization of listed therapies across    NWHs.
(iv) Conduct investigation into allegations of treatment lapses.
(v) Analyze mortality and morbidity under this scheme and recommend corrective measures.
  (vi) Recommend punitive actions against a medical professional or NWH. 

Term No.
9
Term Heading
NWH requirements
Sub Term No.
.1
A NWH shall fulfil the minimum requirements relating to infrastructure, equipment, manpower and services as laid down by the Trust. The requirements are classified under two headings viz., General services requirements and Specialty service requirements based on the Andhra Pradesh Private Medical Care Establishments Act 2002.
The detailed requirements are as specified in Term 6.1
.2
Infrastructure requirements in brief
The network hospitals shall have the following infrastructure.
(i)  A minimum of 50 in-patient medical beds.
(ii) Separate Male and Female General Wards.
(iii) ICU, Post-operative ward with adequate facilities.
(iv) In-house round the clock basic diagnostic facilities.
(v)  Fully equipped Operation Theatre.
(vi) Advanced diagnostic facility either in-house or with tie-up.
(vii) Blood bank facility either in-house or tie-up.
(viii) Pharmacy.
 (ix)  Ambulance.
  (x)  Pantry
.3
Equipment requirement in brief
(a) Outpatient: Specialty wise op instruments
(b) ICU: Bedside Monitors, Ventilators, Oxygen, Suction
(c) Post-operative ward: Bedside Monitors, Oxygen, Suction
(d) Operation theatre:  Equipment, Specialty Wise equipment such as operation table, C-Arm, Endoscopes.
(e) Sterilization: Adequate number of sterilizers.
(d) Casualty: Oxygen, suction, monitors. 
.4
Manpower requirement in brief
(i) Qualified doctor(s) of modern medicine should be physically in charge round the clock.
(ii) Casualty duty doctors and appropriate nursing staff.
(iii) Availability of Qualified or trained paramedics.
  (iv) Availability of specialists in the concerned specialties and support fields within short notice.
.5
Infrastructure needed for the scheme
(i) Separate space and kiosk for running Aarogyasri counter manned by NAMs.
(ii) Computer with networking (Minimum 2 MBPS), printer,       webcam, scanner, bar code reader, biometrics, digital camera       and digital signatures.
.6
Special functionaries to be provided by the NWH
RAMCO: The network hospital shall provide the services of Rajiv Aarogyasri Medical Coordinator (RAMCO) for the scheme.  He will be responsible to the Trust for doing various activities under the scheme including consultation, diagnostics, preauthorization, real time updating of case details, treatment, discharge, follow-up and claims submission. He shall communicate using the CUG (Closed User Groups) Connection provided by the Trust and the web portal of the Trust.
Term No.
10
Term Heading
Obligations of NWH
Sub Term No.
.1
Reception
NWH shall place Aarogyasri Kiosk at the reception or at the patient entry point to the NWH as decided by the Trust for the purpose of reception and registration. It shall provide 2 MBPS Net connection and dedicated computer with peripherals. NWH shall identify, direct and register all the patients holding eligibility card.
.2
 Bi-annual Health checkup
Provide bi-annual Employee Health check up free of cost for the family.
.3
Free pre-evaluation
All the beneficiaries shall be pre-evaluated for the listed therapies till the diagnosis is established.
.4
Counseling for packages where facilities are unavailable
The patient shall be properly counselled and referred to nearby NWH for further management, if found to be suffering from diseases other than those that cannot be managed in the NWH.
.5
Admission and Pre-Authorisation
The beneficiary shall be admitted as per the medical requirement and before pre-authorisation.
 NWH shall send pre-authorisation for all the cases suffering from listed therapies after the final diagnosis and treatment plan along with the required documentation.
.6
Treatment
NWH shall offer complete treatment to the beneficiary as per the standard medical practices choosing best possible mode of treatment.
NWH shall use standard and approved medications, implants and other inputs. NWH shall attend to all the complications arising out during the course of hospitalization and make efforts to complete the treatment irrespective of costs incurred. 
.7
Discharge
NWH shall discharge the patient after satisfactory recovery, duly giving discharge summary.
NWH shall give ten days post discharge medication, return transport fare as per the scheme norms and counsel the patient for follow-up.
.8
Follow up
NWH shall provide follow-up treatment for identified listed therapies under the scheme.
.9
Management of Complications
(i) During hospitalization
NWH shall attend to all the complications arising during the course of treatment in the hospital.
(a)  Related complications: NWH shall attend to all the related 
      Complications, re-do surgeries within the package price.
(b) Unrelated complications: NWH may obtain pre-authorisation
      for unrelated complications due to underlying co-morbid 
      conditions, if the said complication is among listed therapies
      or may apply for package price enhancement.
 (ii) After hospitalization
(a) Related complications: NWH shall attend to all the  complications related to the primary treatment up to the period of one month from date of discharge within the package price.
(b)  Unrelated complications: NWH may obtain pre-authorisation
      for unrelated complications due to underlying co-morbid
      conditions, if the said complication is among listed therapies
(c)  NWH may counsel and refer the patient to the nearest Govt.  
      Hospital for unrelated complication not in listed therapies.
.10
Quality of Services
NWH shall follow the standard medical protocols and use only approved medications, implants and other inputs to ensure quality treatment. NWH shall follow the best medical practices as per the standard medical practices and ensure quality of services for the best outcome of the treatment. The hospital may establish internal medical audit mechanism for the above purpose.
.11
RAMCO Services
NWH shall provide RAMCO services as specified in Term No 9.6.
.12
Health Camps
NWH shall provide health camps in Government Offices as and when required.
.13
Cashless Service
(i)  The beneficiaries are provided with cashless treatment with adequate facilities without the need to pay any deposits right from the entry into the hospital, the commencement of the treatment, the end of treatment till the expiry of 10 days post discharge, for all the procedures covered under the Scheme.
 (ii)  It is envisaged that for each hospitalization the transaction shall be cashless for covered procedures. Enrolled beneficiary will go to hospital and come out without making any payment to the hospital subject to procedure covered under the scheme.
 (iii) The same is the case for diagnostics if eventually the patient does not end up in doing the surgery or therapy.
.14
Limitation of liability and indemnity
(i)  The NWH shall 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. Trust will not be held responsible for the choice of treatment and outcome of the treatment or quality of the care provided by the NWH and should any legal complications arise and is called upon to answer, the NWH will pay all legal expenses and consequent compensation, if any.
(ii) The NWH 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 NWH to answer such claim. In the unlikely event of Trust being proceeded against for such cause of action and any liability was imposed on them, only by virtue of its relationship with the NWH and then the NWH will step in and meet such liability on their own.
(iii) The mere Preauthorization approval of case by Trust or 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 shall be solely responsible for the final diagnosis of disease, choice of treatment employed and outcome on such treatment.
(iv) NWH admits and agrees that if any claim, suit or disciplinary actions by Empanelment and Disciplinary Committee (EDC) arises due to any commissions or omissions of their employees including RAMCO, AAMCO, Billing Head, Data Entry Operator or employees outsourced by them, NWH will be liable for such claim or suit or Disciplinary action.
.15
Confidentiality
(i)   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.
(ii)  The NWH 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 cannot be held responsible for lapse in confidentiality and protecting the information of the patient in the hospital.
(iii) The NWH undertakes 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.
Pre-Authorisation and Claims
Term No.
11
Term Heading
Pre-Authorisation
Sub Term No.
.1
Pre-Authorisation
(i) The Trust shall receive all the pre-authorisation requests from NWHs, scrutinize them as per guidelines issued by the Trust with the help of medical professionals and accord final approval within 12 hours of submission of request by NWH.
(ii) A query on an incomplete pre-authorisation request can be raised  not more than once by the panel doctor. In case of a query by panel doctor, an additional time of 6 hours will be allowed to the Trust so as to enable to offer final approval within 18 hours.
 (iii) Wherever required the services of necessary specialists shall be utilized by the Trust to evaluate special cases.
 (iv) The responsibility & liability of management of a case solely rests with the treating doctor and the NWH. The pre-authorisation remarks of panel doctor or Trust shall be construed as advisory in nature and shall not in any way alter the line of treatment proposed by the treating doctor.
(v)  No recommendation for reduction in package price shall be made  at pre-authorisation stage by the Trust.
(vi) Telephonic approval: The NWH shall obtain Telephonic pre-authorisation through dedicated telephone lines in all cases of emergencies. NWH shall only obtain a telephonic approval after confirming that the particular case falls within the purview of the scheme. A telephonic pre-authorisation shall be deemed to be a provisional approval, and shall necessarily be followed by a regular pre-authorisation within 24 hours.
(vii)The rejection of pre-authorisation by Trust shall not be construed as refusal of treatment to the patient by the Trust. The rejection of pre-authorisation merely means the disease of the patient and treatment choices are out of the listed therapies. 
(viii) The approval of pre-authorisation by the Trust shall be based on online evidence of diagnosis and choice of treatment arrived at by the treating doctor. The approval by Trust shall be deemed as an approval of the case for financial assistance under the scheme and shall not be construed as an endorsement of treatment by the NWH.
(ix) Enhancement (Package price adjustment): The NWH shall provide end to end cashless services within the package. However NWH may apply for enhancement of the package price in case of exigencies prior to discharge as per Trust guidelines. 
.2
24-hr e-Preauthorisation
(i)                 All pre-authorisations shall be handled by the Trust through existing online e-preauthorisation workflow. Trust shall establish necessary IT infrastructure to handle additional load of pre-authorisations on account of scheme.
(ii)               The pre-authorization shall be done 24x7x365 days.
.3
Scheme Technical Committee
A technical committee for the scheme, herein after called “The scheme technical committee” shall exercise the following powers of recommendation to the CEO:
1.      Final decision on pre-authorizations in case of difference of opinion.
2.      Authorization of utilization of “buffer amount”;
3.       Authorization of Package Price enhancements or Pricing for unlisted therapies to be paid from the buffer;
4.       Modification of nomenclature and relocation of any listed therapy;
5.      Minor changes in protocols for the listed therapies;
6.      Framing of guidelines and evolving objective criteria to assist proper selection of cases in order to reduce moral hazard.   
.4
Composition of Scheme Technical Committee
The scheme technical committee shall consist of the following members:
1.                  Executive Officer (Technical);
2.                  Joint  Executive Officer (Technical) and
3.                  Medical Doctor nominated by the Government.
Term No.
12
Term Heading
Claims
Sub Term No.
.1
Claim Processing
(i) All the claims processing shall be carried out electronically through the Trust portal.  Payments to all the NWHs shall be made through electronic clearance facility of the Trust.
(ii)  The claim intimation, collection of claim documents, scrutiny of claim documents shall all be done through the Trust portal.
(iii) The Trust shall follow the claim control number generated by the Trust portal for further reference.
.2
(i) The grant of pre-authorisation by the Trust shall constitute the prima-facie evidence for any claim. Admission of a claim rests solely on three conditions viz., grant of pre-authorization for the listed therapy including changes in listed therapy necessitated by the exigencies of the case during management and intimated to the Trust within the shortest possible time, claim amount being limited to pre-auth amount, and evidence of performance of a listed therapy. An intra operative photograph or a scar photo or a case sheet is sufficient evidence for settlement of a claim. Decision of Trust on any claim settlement shall be final.
 (ii) As soon as the claim lands with the Trust, the following verification alone needs to be performed.
(a) Verification of identity of the patient
(b) Verification whether the claim amount is limited to pre-authorised amount.
(c) Verification of case management as per the pre-      authorisation.
(d) Verification of evidence of treatment. 
.3
(i) Upon the performance of a listed therapy the NWH initiates a  claim. The claim will consist of the identity of patient, pre-authorized listed therapy and pre-authorized amount with enhancement if any, and evidence of performance of listed therapy in the form of an intra-operative photograph or a scar photograph linking the identity of the patient with the therapy or case sheet.
(ii) The Trust upon receipt of the claim shall verify the identity,  listed therapy, amount of the claim and evidence.
(iii) Upon confirmation by means of a photograph or a medical record such as a case sheet that the listed therapy has been performed, the claim shall be settled and payment made to the NWH within 7 days.
(iv) If the Trust is unable to establish the performance of the listed therapy in the first round of claims scrutiny, the Trust will be allowed to return the claim requesting for specific information from the NWH. Any such request or clarification by the Trust shall not result in additional investigations or diagnostic reports to be performed afresh by the NWH.
(v) The Trust shall be allowed to send a claim back to NWH for any clarifications only once before final settlement. All remarks relating to the claim ranging from non-medical to medical queries shall be consolidated before being sent back to the NWH.
(vi) An additional time of 7 days will be allowed in case of claim is sent back to the NWH for clarification.
(vii)   The Trust issues guidelines from time to time for pre-         authorisation and claims settlement which shall be followed scrupulously.
.4
Claim reduction and repudiation
(i)            Reduction: The settlement of a claim shall be to the full extent of the package price or pre-authorization amount whichever is lower. No disallowance can be made to a claim unless approved by the scheme technical committee of the Trust. 
(ii)          Repudiation: The Trust may repudiate a claim for reason of not being covered by the policy under intimation to Scheme Technical Committee.
(iii) An appeal lies to the Appellate Committee either against repudiation (rejection) as defined in Term 12.4 (ii) or reduction of claim as defined in Term 12.4 (i) under Term 12.5 within 3 months from date of repudiation advice or settlement of claim.
.5
Appeal
(i) The NWH shall have a right of appeal to approach the appellate committee consisting of the Chief Medical Auditor, a member selected by the Trust from out of the panel of specialist doctors not related to the NWH and provided by the NWH, under the chairmanship of CEO. The quorum for this committee shall be three members present and voting, and majority opinion shall prevail. The decision of this appellate committee shall be final and binding on the Trust and the NWH. This right of appeal shall be mentioned by the Trust in every repudiation advice given as per Term 12.4.
(ii) The Appellate Committee shall have the power to re-open a  
     claim if properly supported by documentary evidence.
(iii) The Appellate Committee shall have the right to reopen a settled claim and direct the Trust to settle for an appropriate amount within a period of 3 months of settlement of the claim. The Trust further agrees to provide access to the Appellate Committee their records for this purpose. All the claims settled by the Trust  to the network hospitals based on the bills received from the hospitals in conformity with the package price  arrived at and also based on the pre-authorization given by the Trust shall be reckoned as final and not subject to any reopening by any authority except Appellate Committee. 
.6
Claim float and Bank Account
The Trust shall have a separate Bank account to pay the NWH making a valid claim and all payments will be electronically cleared on the Trust portal.  Detailed reports will be made available online on a real-time basis.

Implementation Process
Term No.
13
Term Heading
Patient Process Flow
Sub Term No.
.1
 Mode of OP capture
 A beneficiary suffering from an ailment can approach any of the following ‘first point of contact’ for registration under the scheme. The mode of OP capture is directly at the NWH in case of emergencies or through referral.
.2
OP Process flow at the NWH
(i) Arrival: The beneficiary arrives at the NWH kiosk either with a referral card or with a complaint for registration.
(ii) Registration: NAM first mandatorily registers the Identity, Eligibility, Contact and Complaint (I, E, C and L) in case the patient is adult.  In case the patient is a child, the patient’s Identity and Complaint (I & L) and parent’s identity, eligibility and contact (I, E, C) are registered.   OP is registered and OP ticket issued.
(iii) OP Consultation: Patient is forwarded to the OP and gets counselled to ascertain the eligibility under Scheme. Investigations are prescribed if required.
 (iv) Investigations: He thereafter moves to the Investigation facilities if required, gets tested and returns to the doctor.  If he can be treated as an OP case, prescription is given.  The Diagnosis and prescription are entered in the system by NAM and case disposed.
 (v) Uncovered OP Procedure: If the patient’s treatment warrants use of any of the uncovered OP, the RAMCO enters the details in the system and refers the case to Government Hospital.
(vi) IP registration: If the patient’s treatment warrants use of any of the Listed Therapies, the RAMCO enters the details of Procedure and Investigations in the system, converts the case to IP, sent to the ward concerned (semi-private or private based on the eligibility) and raises preauthorisation.
.3
Evaluation and Admission
After the initial evaluation of the patient, the patient is admitted if needed and evaluated further.  The patient may be evaluated as an out-patient initially and after ascertaining the diagnosis and finalization treatment mode admitted and converted as “in-patient” in the online workflow.   
.4
Final diagnosis and categorization
After the evaluation of the patient:
(i) If the patient is found to be suffering from listed therapies,  RAMCO shall submit the pre-authorisation through the Trust portal within 24 hours.
(ii) If the patient is found to be suffering from diseases other than  those that cannot be managed in the NWH or not covered in the Listed therapies, he shall be counselled and referred to nearest suitable Hospital for further management.
.5
Pre-authorisation
RAMCO shall upload all the relevant documents and send the case for pre-authorization.
.6
Treatment
The NWH shall render complete treatment to the patient after obtaining pre-authorization. Any complications arising during the course of hospitalization shall also be attended to.
.7
Discharge
The patient is discharged after complete recovery. The NWH shall issue discharge summary, 10 days post-discharge medication, counsel the patient for follow-up. A letter of satisfactory services shall be obtained from the beneficiary at the time of discharge.
The patient is reimbursed transport charges as per the scheme norms and obtains receipt.
RAMCO shall upload the documents.   
.8
Follow-up
Patient shall be provided follow-up services as per the standard medical norms duly counselling and recording the same in the discharge summary.
The follow-up packages provided under the scheme shall be utilized for this purpose to provide cashless follow-up services.
.9
Claim submission
The NWH will raise the claim after the 10 days of satisfactory discharge of the patient. 
.10
Emergency Registration and Admission
All the beneficiaries shall be admitted by a NWH and treated immediately. RAMCO or treating doctor shall obtain emergency telephonic pre-authrorisation through dedicated round the clock telephone lines of the Trust, if the patient is suffering from listed therapies.
If the patient is suffering from diseases other than listed therapies he must be counselled and facilitated safe transportation to the nearest Government Hospital.
If the patient’s condition warrants shifting him to a higher centre, safe transport shall be facilitated to other NWH if suffering from listed therapies.

Term No.
14
Term Heading
Trust Office Functions
Sub Term No.
.1
Location
The Offices of the Trust shall house the staff administering the Scheme.
.2
Back Office Departments
(a) Round-the-Clock Pre-authorization wing with specialist doctors for each category of diseases shall work along with the Trust doctors to process the preauthorization within 12 hours of the electronic request by the network hospital on the web portal of the Trust.
(b)  Claims settlement wing with required staff shall function to settle valid claims within 7 days.  
 (c) IT and MIS wing
(i) IT wing with required staff shall ensure that the entire process of back office operations of e-preauthorization, claim settlement, grievance redressal, and other activities dependent on the Trust portal are maintained on real-time basis.
(ii) MIS wing shall collect, collate and report data on a real-time basis. This department will collect, compile information from field staff of the Trust and generate reports as desired by the Trust.
(d) Call Centre The Trust portal receives calls through 104 Call Centre handling all the incoming and outgoing phone calls, grievances received through various means. The Trust provides executive support for the purpose of guiding and redressing the grievances of the stake holders.  This service shall be referred to as the “Call Centre Service”. Queries relating to coverage, benefits, procedures, network hospitals, cashless treatment, balance available, claim status and any other information under the scheme anywhere in the state on a 24x7 basis shall be answered in Telugu.
(e) Grievance wing
 (i) Shall send feedback formats, collect and analyze feedback of the patients as per the directions of the Trust. The department will also document each case and upload the same in the Trust portal. The Trust shall also collect the satisfaction slip from the beneficiaries at the time of discharge who had obtained the cashless services. The beneficiaries shall submit the Satisfaction slip issued by the Trust at the time of discharge through Provider. The Trust shall also carry out the Customer Satisfaction Survey by using the rating card for the purpose.
(ii) The wing shall be manned by doctors and other staff to address the grievances from time to time as per the guidelines. The Trust shall also attempt to solve the grievance at the field level. The Trust shall provide the beneficiaries or NWH with details of the follow-up action taken as regards the grievance as and when the beneficiaries require it to do so.
(iii) The Trust shall record in detail the action taken to solve the grievance of the beneficiaries NWH in the form of an Action Taken Report (ATR) within 2 working days of the recording of the grievance. The Trust shall provide the Government with the comprehensive action taken report (ATR) on the grievances reported in pre-agreed format. The entire process will be done through the call center and Trust portal. The Trust shall co-ordinate with Provider in order to solve the grievance as and when required by the nature and circumstances of the grievance.
(f) Administration, Training and HR wing with required staff for purposes of office management, legal matters, accounts. It will manage human resources, arrange the workshops / training sessions for the capacity building of the stakeholders in respect of the scheme and their roles.
Term No.
15
Term Heading
Field Operations
Sub Term No.
.1
District unit
(a) The Trust will have a District Coordinator in-charge of each district. The District Coordinator shall coordinate with the Trust in implementation of the scheme. The District Coordinator monitors Aarogyamithra services, health camps, beneficiary services and grievances.
(b) The district units of the Trust handle all the schemes operated by the Trust including this scheme.

Term No
16
Term Heading
Web portal and online workflow
Sub Term No.
.1
Web Portal:
(i)  The Trust website with e-preauthorization, claim settlement and real-time follow-up is maintained and updated on a 24-hour real-time basis. The source code and system design document for the application was developed and owned by the Trust.  The IT application is being developed and maintained as per dynamic requirements of the Trust schemes.  A dedicated data centre is being maintained by Trust for this purpose.
(ii) The website is a repository of information and has the following information or features:
1.                  General Information on the scheme.
2.                  Details of patients reporting and referrals from the
3.                  PHC/CHC/Government Hospitals/ District hospitals on daily
basis.
4.                  e-Health Camps system and daily reporting of health camps.
5.                  Details of patients reporting and getting referred from the
health camps.
6.                  Empanelment module.
7.                  Emergency approval system
8.      Call centre module
9.       Patient registration module operated by Aarogyamithras in
Network Hospitals
10.              Details of in-patients and out patients in the network hospitals
11.              On-bed reporting system.
12.               Preauthorization module
13.              Surgery details.
14.              Discharge details.
15.              Real-time reporting, active data warehousing and analysis   
           system.
16.              Claims module
17.              Electronic clearance of bills with payment gateway
18.              Follow-up of patient after surgery
19.              Follow-up services.
20.              Aarogyasri Messaging Services.
21.              Enhancement workflow
22.              Grievance and Feedback workflow
23.              Bug Tracking system
24.              Accounting module
25.              TDS or Service Tax workflow.
26.              Death reporting system.
27.              Biometrics and Digital Signatures
28.               Analytical tools including BI (Business Intelligence or Service Intelligence)
.2
IT backbone
A dedicated real-time online workflow system was designed by the Trust in order to bring dynamism and decentralization of work in a massive scheme like Aarogyasri. This includes total online processing of the cases starting from registration of case at first referral center (health camps or network hospitals or other sources), pre-authorization, up-load of medical and non-medical records electronically, treatment and other services at the hospital, discharge  and post treatment follow-up, claim settlement, payments through payment gateway, accounting system, TDS deductions till the end. Any inputs for improvement of the system will be taken from all the stake holders from time to time.
Term No.
17
Term Heading
Project Monitoring - Implementation Committees – State and District.
Sub Term No.
.1
Monitoring Committees
Regular review meetings on the performance and administration of the scheme will be held by the Trust. The following shall be the composition of the monitoring committees at the District and State levels.
(a) Aarogyasri District Monitoring Committee:
Chairman:   District Collector
Members: 
1.    Project Director, DRDA
2.    District Medical and Health Officer
3.    District Coordinator of the Trust (Member- Convener)
4.    District Coordinator of Health Services (DCHS)
(b) State monitoring committee:
Chairman: CEO of Aarogyasri Health Care Trust.
Members:
1.                  Executive Officer (Technical)
2.                  Head Field Operations
3.                  Joint Executive Officer (PMU)
4.                  A representative of Government
The Chairmen of the above committees may invite any non-official member in the project districts for the meetings. Periodical meetings will be organized at both district and State level. The agenda and issues to be discussed would be mutually decided in advance. The minutes of the meeting at the district and state level will be drawn and a copy will be forwarded to Trust. Detailed reports on the progress of the scheme and issues if any emerging out of such meetings shall be reported to GoAP or Trust.
.2
Grievance Rederessal
(i) At the district level, the district committee specified at Term 17.1 (a) shall redress the grievances and its decisions shall be binding except when an appeal to the state level committee is preferred.
 (ii)The state level committee specified at Term 17.1 (b) will entertain all the appeals and grievances at the state level. The decision taken by the committee will be final and binding on both the parties.
.3
Coordination
The Trust shall coordinate with all stake holders for implementation of activities like empanelment of hospitals, planning for camps, registration of patients.
Term No.
18
Term Heading
Packages
Sub Term No.
.1
Package definition
Package  includes  the following services:
1.    End-to-end cashless service offered through a NWH from the time of reporting of a patient till ten days post discharge medication, including complications if any up to thirty (30) days post-discharge, for those patients who undergo a “listed therapy(ies);
2.     Free evaluation of patients for listed therapies who may not undergo treatment for “listed therapies”; and
3.     Other services as specified in Term 19.3
.2
Description of packages
For each hospitalization the transaction shall be cashless for “listed therapies”. A beneficiary shall go to the hospital and come out without making any payment to the hospital after treatment. The same shall hold true for diagnostic services if eventually the beneficiary does not end up undergoing any listed therapy.
The general guidelines published by the Trust separately from time to time shall be followed while providing services under the  packages.
.3
(a)      Elaboration of services under package
(b)    The services under the package include:
1.            Stay: Stay consists of bed charges in ICU, Post-Operative ward and semi private and private wards and nursing charges.
2.            Inputs: Inputs include O.T. Charges, O.T. Pharmacy, O.T. disposables and consumables, implants, blood and blood related products, General Pharmacy, Oxygen, Consumables and disposables.
 Professional fees: Consultant and In-house doctor charges.
3.            Investigations: All the biochemistry, pathology, micro biology and imageology investigations for diagnosis and management of the patient.
4.               Miscellaneous: Diet and transportation charges. Prescribed quality food sourced from in-house facility or from an external vendor shall be provided. Return transport fare between the pateint’s resident Mandal Headquarters and the NWH equivalent to RTC fare or Rs.50 whichever is minimum shall be paid.
(b) Blood and blood related products
Blood shall be provided either from an in-house blood bank or “tie up” blood bank subject to availability. The hospital shall provide blood from its own blood bank subject to availability within the package. In case of non-availability efforts shall be made to procure blood from other blood banks run by Red Cross, voluntary organizations etc. Assistance shall be provided to the patients to procure compatible blood for the surgeries by issuing a copy of the request letter to the patient.
.4
Packages under special listed therapies
 (i) Package under Cancer therapies:
1.   Chemotherapy and radiotherapy shall 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 of the treatment.
2.   Patients with hematological malignancies- (leukemias, lymphomas, multiple myeloma) and pediatric malignancies (Any patient < 14 years of age) shall be treated by qualified medical oncologists only.
3.   Advanced radiotherapy procedures shall be utilized only for the cases and diseases which do not respond to conventional radiotherapy.
4.   Tumors not included in the listed therapies and that can be treated with any listed chemotherapy regimen, proven to be curative, or providing long term improvements in overall survival shall be reviewed on a case to case basis by the “Scheme technical committee”.
(ii) Package under Poly trauma category:
1.   The components of poly trauma category are Orthopedic trauma (surgical Corrections), Neurosurgical Trauma (Surgical and conservative management), Chest Injuries (surgical and conservative management) and Abdominal injuries (surgical and conservative management). These components may be treated separately or combined as the case warrants.
2.         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.
3.    In case of Neurosurgical trauma, admission is based on both  Imageological evidence and Glasgow Coma Scale (A scale of less than 13 is desirable).
4.    All surgeries related to poly-trauma are covered irrespective 
 of hospitalization period.
5.    Initial evaluation of all trauma patients shall be free.
Term No.
19
Term Heading
Follow-up Packages
Sub Term No.
.1
Follow-up Packages
Follow-up packages are funded by the buffer and cover the entire cost of follow-up.
(i) The scheme provides for follow-up Packages for all the therapies to cover entire cost of follow-up i.e., consultation, medicines, diagnostic tests etc., to enable beneficiary to avail cashless follow-up therapy for long term period to obtain optimum benefit out of the primary listed therapy and avoid complications.
The NWH will provide follow-up services under the packages and costs will be directly paid by the Trust to NWH. (ii) Guidelines for these packages are as stated below.
(a) The Follow-up treatment shall be entirely cashless to the patient and will start on 11th day after the discharge and will continue for one year after 11th day of discharge. The follow-up package will be renewed along with the scheme for each year.
(b) No formal pre-authorization is required.
(c) For operational convenience package amount is apportioned into 4 quarters. Since frequency of visits and investigations mostly take place during first quarter, more amount is allocated for first instalment.
(d) Patient follow-up visits may be spaced according to medical requirement. However approval will be given for one quarter.
(e) RAMCO along with NAM shall facilitate patient follow-up.
                  The Scheme Data (TSD)
Term No.
2
Term Heading
Salient Features
Sub Term No.
.3
Beneficiaries: The number of serving employees and pensioners as stated by the Director Treasuries as on 24.12.2011 is as stated in the table below.
Total number of families to be covered: 13,25,800
Total number of Beneficiaries: 42 lakhs calculated at the rate of  3 persons per family.
No. of Gazetted staff                -     50298
No. of Non-gazetted staff         -    728898
No. of Pensioners                     -    546612
Family: Family will constitute
·         dependent parents,
·         spouse,
·         children below 18 years,
·         handicapped children,
·         dependent children above 18 years as certified by DDO before the start of yearly policy period. 
In case of both husband and wife are employed, the contribution can be paid by both, and the dependent parents of the wife will also be covered.  This is however optional.
.4
Process of Verification:-  As given in table below.
.8
Coverage limit: Rs.3:00 lakhs per family per annum on family floater basis and Rs.2:00 lakhs per individual.
.9
Buffer Sum:
A sum of Rs. 175 Cr. from the total fund collected shall be provided as Buffer or corporate floater for the scheme to meet:
(i) OP treatments for identified long term diseases
(ii) High end and high cost procedures
(iii) Treatment done outside the state with telephonic approvals.
(iii) Treatment for unlisted procedures.

Term No 2.3
Department wise breakup of beneficiaries:
The number of serving employees and pensioners as stated by the Director Treasuries is as stated below.
(a)   Serving Employees (Finance Department, Appendix 2011-12, Budget dt. 13.12.2010)
S. No.
Category (2010 Scales)
(Rs 6700-20100 to 13660-38570)
(Rs 14860-39540 to Rs 21820-48160)
(Rs 23650-49360 to Rs 44740-55660)
Scale Not specified
Grand Total
Grade III
Grade II
Grade I
(I)
STATE GOVERNMENT
445804
79282
6019
531105
(II)
SCHOOL EDUCATION
1
Government Including Teachers)
14291
10911
75
25277
2
B.Ed Colleges
57
62
6
125
3
Zilla Parishads
33326
52679
0
86005
4
Mandal Parishads
154191
21037
0
175228
5
Municipalities
9373
3801
0
13174
6
Hindi Vidyalaya
21
13
0
34
7
Vocational Education
819
0
0
819
8
Oriental Schools
829
297
0
1126
SCHOOL EDUCATION(Sub Total)
212907
88800
81
301788
(III)
INTERMEDIATE EDUCATION
1
Government(Including Lectures)
5329
13172
8
18509
2
Private Aided Junior Colleges
1975
3510
1
5486
INTERMEDIATE EDUCATION (Sub Total)
7304
16682
9
23995
(IV)
Others
1
Cadre Posts
390
390
2
Judicial(including NJPC)
1396
1396
3
Sales not mentioned
1385
1385
4
UGC & Central
1537
1537
Others(Sub Total)
4708
4708
Grand Total
666015
184764
6109
4708
861596
Term No 2.3
(b) Pensioners (DTA, 31.08.2010)
S.No.
District
No of Service Pensioners
No of Family Pensioners
Total
1
JD PPO,Hyderabad
51075
35504
86579
2
Adilabad
5399
4644
10043
3
Ranga Reddy
3483
2703
6186
4
Karimnagar
11427
6557
17984
5
Khammam
7927
5655
13582
6
Mahboobnagar
9471
7261
16732
7
Medak
6935
4912
11847
8
Nalgonda
9734
7440
17174
9
Nizamabad
6796
4990
11786
10
Warangal
13148
8266
21414
11
Kurnool
12802
10201
23003
12
Ananthapur
11122
9149
20271
13
Chittoor
14030
9702
23732
14
Kadapa
10704
7823
18527
15
Srikakulam
8914
6192
15106
16
Visakapatnam
13406
8465
21871
17
Vizianagaram
7650
5810
13460
18
East Godavari
20479
14785
35264
19
West Godavari
15377
9906
25283
20
Krishna
19826
11633
31459
21
Guntur
21683
14167
35850
22
Prakasam
11958
7952
19910
23
Nellore
11921
8070
19991
Total
305267
211787
517054
*at an average of 3 persons per family
Total number of families to be covered: 13,78,650
Total number of Beneficiaries: 42 lakhs

Term 2.4 (before health card issue)
Treatment for self
Treatment for dependent
Authentication Details
Information Sources
Authentication agent
Information Sources
Authentication agent
1.Employee Name and details
Database of Finance dept.
NAM
Database(Finance dept.)
NAM
2. Employee Photo
Dept. Photo ID/ /Database of Civil supplies( online ration card)/ Any of 14 Photo Ids
NAM
Dept. Photo ID/ /Database of Civil supplies( online ration card)/ Any of 14 Photo Ids
NAM
3. Dependent name and relationship
-NA-
-NA-
Database of Civil supplies( online ration card)/ DDO Photo certificate
NAM
4. Dependent Photo
-NA-
-NA-
Database of Civil supplies( online ration card)/ DDO Photo certificate
NAM

Term No.
3
Term Heading
Benefit Coverage
Sub Term No.
.1
Out-Patient
(i)      Out-Patient treatment for long term diseases such as hypertension, diabetes, endocrine disorders, rheumatoid arthritis etc.,
(ii)    Follow-up treatments
.2
In-patient: The scheme shall provide coverage for the listed therapies in all the systems. The list is provided in the Annexure-1.
.5
Follow-up Services: Network Hospitals will provide free follow-up services to the patients for all the required procedures through packages.
Term No.
4
Term Heading
Policy period and contribution
Sub Term No.
.1
Budget
Trust estimated budget requirement of Rs.350 Cr. per annum based on the coverage to be provided and present expenditure on account of reimbursement bills.
.3
Payment of contribution
(i) Government will provide Rs.210 Cr. towards corpus fund for   premium, buffer, other claims for uncovered procedures.
(ii) Rs.50 Cr. will be provided to meet initial expenditure on account of infrastructure requirement including smart cards.
(iii) Rs.140 Cr. shall be contributed by the employees through a graded premium of following rates.
Graded contribution* based on the 2 categories of eligibility as per Gazetted or non-Gazetted.
(i)       Gazetted- Contribution Rs.120 per month  – Eligible for private room
(ii)     Non-Gazetted– Contribution  Rs.90 per month – Eligible for sharing room
* The calculation of contributory premium is based on the number of families belonging to above categories as provided by the Finance Department.
Term No.
6
Term Heading
Empanelment
Sub Term No.
.1
Empanelment Criteria:
Eligible Network Hospitals:  As on date 344 hospitals are empanelled under the scheme. The list is given at Annexure-2.

B. STAFFING
S. No
Department
Designation proposed as per HR Policy
Qualification
Mode of appointment
No. of
posts
1
Administration
Head of the Dept. (HoD)
MBBS Doctor in the rank of Addl. Director
Deputation
1
Head of the Dept. (HoD)
Addl. Director rank
Deputation/Contract
1
DGM (NT)
Joint Director level
Deputation/Contract
1
DGM (NT)
Joint Director level
Deputation/Contract
1
Deputy Manager (NT)
Graduate with experience preferably in health insurance
Contract
4
2
Pre-authorization
DGM (T)
MBBS doctor Joint Director level
Deputation/Contract
5
Deputy Manager (T)
MBBS doctor
Deputation/Contract
5
Deputy Manager (NT)
Graduate with experience preferably in health insurance
Contract
2
3
Claims
DGM (T)
MBBS doctor Joint Director level
Deputation/Contract
3
Deputy Manager (T)
MBBS doctor
Deputation/Contract
2
Deputy Manager (NT)
Graduate with experience preferably in health insurance
Contract
2
4
Grievance Redressal
DGM (T)
MBBS doctor Joint Director level
Deputation/Contract
2
Deputy Manager (T)
MBBS doctor
Deputation/Contract
2
Deputy Manager (NT)
Graduate with experience preferably in health insurance
Contract
2
5
Preventive Health check
DGM (T)
MBBS doctor Joint Director level
Deputation/Contract
2
Deputy Manager (T)
MBBS doctor
Deputation/Contract
2
Deputy Manager (NT)
Graduate with experience preferably in health insurance
Contract
2
6
Planning
DGM (T)
MBBS doctor Joint Director level
Deputation/Contract
2
Deputy Manager (T)
MBBS doctor
Deputation/Contract
2
Deputy Manager (NT)
Graduate with experience preferably in health insurance
Contract
2
7
Hospital Coordination
DGM (T)
MBBS doctor Joint Director level
Deputation/Contract
2
Deputy Manager (T)
MBBS doctor
Deputation/Contract
2
Deputy Manager (NT)
Graduate with experience preferably in health insurance
Contract
2
8
Accounts
DGM (NT)
Commerce Graduate with 10 years experience in accounting
Deputation/Contract
1
Deputy Manager (NT)
Commerce Graduate with 5 years experience in accounting
Deputation/Contract
2
9
PMU(IT)
Head of the Dept. (HoD)
MBA/Engineering Graduate
Contract
1
Deputy Manager  (T)
MBA with IT background
Contract
2
10
Legal
DGM / AGM
LLB
Contract
1
Deputy Manager
Graduate
Contract
2
11
DPOs
Junior Executive
Executive
Senior Executive
Graduate with DCA
Outsourcing
10
12
DEOs
Junior Associate
Associate
Senior Associate
Graduate with Computer experience with typing skill
Outsourcing
15
11
Attenders
Sub-Staff-Attenders
10th class
Outsourcing
10
12
District offices
DGM (T)
MBBS Doctor
Deputation/Contract
23
Office Associate
Graduate with Computer Knowledge
Outsourcing
23

 Each staff shall have the following minimum eligibility criteria and responsibilities
A
Project Manager and Office Staff
Staff
Qualifications, experience and skills
Responsibilities
1.Pre-authorisation Executive
(a)Qualifications: A Graduate with Computer Knowledge and typing in lower division .
(b)Experience: In Health Insurance Desirable.
(c)Skills:
i. Good computer knowledge. 
ii. Good documentation and communication skills.
iii. Demonstrated experience with and knowledge of computerized data collection, management, reporting and analysis systems, and
iv. Shall have thorough understanding of aims and objectives of Aarogyasri scheme.
i. Report to Team Lead.
ii. Shall peruse the online pre-authorisation request, analyse the non-medical social parameters, eligibility criteria, mandatory medical and non-medical attachments.
iii. Record and report the deficiencies if any in pre-authorisation requests.
iv. Reach targets fixed as per the SLAs.
2.Claim Executive
(a)Qualifications: A Graduate with Computer Knowledge and typing in lower division.
(b)Experience: In Health Insurance Desirable.
(c)Skills:
i. Good computer knowledge. 
ii. Good documentation and communication skills.
iii. Demonstrated experience with and knowledge of computerized data collection, management, reporting and analysis systems, and
iv. Shall have thorough understanding of aims and objectives of Aarogyasri scheme.
i. Report to Team Lead.
ii. Shall peruse the online claims submitted by the NWHs, ascertain completeness of the claim in terms of filling of all the clinical documents such as case sheet, discharge summary, post pre-auth notes and note any discrepancies in the dates, days in these documents. 
iii. Verify the availability of mandatory medical and non-medical records in the claims attachments and record the deficiencies if any in claim.
iv. Reach targets fixed as per the SLAs.
3. Other Executives
(a)Qualifications: A Graduate with Computer Knowledge and typing in lower division.
(b)Experience: In Health Insurance Desirable.
(c)Skills:
i. Good computer knowledge. 
ii. Good documentation and communication skills.
iii. Conversant with office procedures
iv. Demonstrated experience with and knowledge of computerized data collection, management, reporting and analysis systems
v. Shall have thorough understanding of aims and objectives of Aarogyasri scheme.
i. Report to Team Lead.
ii. Shall collect the grievances and complaints and analyse the content of it.   
iii. Collect and compile the relevant information from concerned sources such as, online documentation from Aarogyasri portal, hospital explanations if any, previous records related to these complaints if any.
iv. Notify the team lead about the grievances and their analytical outcome.
v. Assist other departments such as health camps, legal, HR. 
iv. Reach targets fixed as per the SLAs.
4. Team Lead
(a)Qualifications: A Graduate with Computer Knowledge.
(b)Experience: Minimum 2 years In Health Insurance .
(c)Skills:
i. Good leadership skills. 
ii. Able to command group of executives.
iii. Good documentation and communication skills.
iv. Analytical skills
v. Conversant with office procedures
iv. Demonstrated experience with and knowledge of computerized data collection, management, reporting and analysis systems
v. Shall have thorough understanding of aims and objectives of Aarogyasri scheme.
i. Report to Project Head.
ii. Shall supervise the work of executives.
iii. Shall guide the executive in quality completion of work
iv. Shall impart knowledge and training to the executive.
v. Shall analyse the grievances and evidences submitted by the executive.   
iii. Shall resolve the grievances to the best of his ability.
iv. Report to Project Head on resolved and unresolved grievances.
v. Assist other departments such as health camps, legal, HR. 
iv. Reach targets fixed as per the SLAs.
5.Supervisor
(a)Qualifications: A Graduate with MBA with Computer Knowledge.
(b)Experience: Minimum 3 years In Health Insurance .
(c)Skills:
i. Good leadership skills. 
ii. Able to command group of Team Leads.
iii. Good documentation and communication skills.
iv. Analytical skills
v. Conversant with office procedures
iv. Able to lead and guide subordinate staff.
v. Shall have thorough understanding of aims and objectives of Aarogyasri scheme.
i. Report to Project Head.
ii. Shall supervise the work of subordinate staff.
iii. Shall guide the subordinate staff in quality completion of work
iv. Shall impart knowledge and training to the subordinate staff.
iv. Ensure that team achieves targets fixed as per the SLAs.
6.Doctors
(a)Qualifications: MBBS or Post Graduate degree or diploma in specialties.
(b)Experience: Desirable In Health Insurance.
(c)Skills:
i. Good leadership skills. 
ii. Able to comprehend online medical evidences and EMRs
iii. Good documentation and communication skills.
iv. Analytical skills
v. Shall have thorough understanding of aims and objectives of Aarogyasri scheme.
i. Report to Lead.
ii. Shall analyze and assess the pre-authorizations and claims and give approvals after due verification.
iii. Shall guide the subordinate staff in quality completion of work
iv. Achieve targets fixed as per the SLAs.
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