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SANJEEVANI “Sampoorna Kutumba Arogya Pathakam” (SKAP)

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Presentation on theme: "SANJEEVANI “Sampoorna Kutumba Arogya Pathakam” (SKAP)"— Presentation transcript:

1 SANJEEVANI “Sampoorna Kutumba Arogya Pathakam” (SKAP)

2 Benefits of the Scheme Free OPD consultation Fixed Discount on Diagnostics Fixed discount on Medicines Hospitalization Cover for Surgeries Hospitalization Cover for Medical Conditions Weekly consultation with lady doctor at their door step Community Development Activities Pre existing diseases are covered Treatment to be taken at Network Hospitals Only Treatment in General ward only

3 1. Out Patient Consultation PHC level: consultation with lady doctors once in a week free of cost Network Hospital (NWH): consultation free of cost 2. Diagnostics: Basic diagnostics will be done at PHC free of cost Diagnostics at NWH will be done at a fixed discounted rate. 3. Quality Medicines 1. Free of cost at PHC level 2. 10% Discount rate at NWH 3. Grossly discount at Drug depots of IKP (Sanjeevani Pharmacy)

4 4. Medical and Secondary and Tertiary Surgical Care treatment provided through Referral Network Hospitals, sum insured up to a maximum amount of 30000/- Covers more than 1500 surgeries –includes all categories of complex and common surgeries OBG – includes normal delivery, LSCS and Hysterectomy General Surgery Gastroenterology Orthopaedics – includes fracture surgeries Genito-Urology Endocrinology ENT 100% Cashless facility

5 5. Hospitalization cover: Cover- Inpatient treatment requiring hospitalization for more than 24 hours. Maximum amount payable is Rs 5000/- under the Family Package 5 Cover would include consultation, investigation and room charges, medicines and consumables. 10% of Co-Payment on the final bill.

6 Premium For family of 5-Rs. 260/year Age Limit: 0-60

7 Process of Availing Treatment Beneficiary approaches VO Representative VO rep explains scheme Beneficiary goes Network hospital with ID Card, Receipt Admission for Surgery Free OPD Consultation Investigation Special rates CASHLESS Hospitalization Medical treatment Patient pays 10% of the bill Member signs on the Claim Form STAR T Discharge Intimation to TPA/ZS by NWH Pre-Authorization- from TPA/ZS

8 Preauthorization When a beneficiary is advised surgery/medical treatment by NWH, the Hospital sends a Pre- authorization to the ZS office seeking approval to conduct the surgery under the Scheme. The medical officer at the ZS approves the Preauthorization if all documents and requirement is in order. In case of emergency, the Coordinating Officer at NWH shall take verbal sanction from the Implementing Agency and proceed with the surgical/medical treatment. The preauthorization for the same shall be sending to the Implementing Agency within 24 hours. Documents to be sent: Photocopy of the ID Card

9 General Exceptions Sent to Hospital for supporting reports verification Eligibilit y Yes Complicated cases Eligible No Receive of Intimation from Hospital Generation of Pre-Authorization Serial No. Complicated/Ge neral/ Exceptions Sent to VO Rep for verification A-Eligibility Verification ID card, Receipt, Residential Proof B-Medical verification Data entry into Software START STOP Letter of Rejection to Hospital Authorization letter to hospital Medical Officer checks and fixes rate Letter of Rejection to Hospital NO

10 Claim Process The Claim Form from the Hospital should be accompanied  Photocopy of the I.D. Card  Original claim form with the signature of the beneficiary.  Final split – up bill – with the signature of the beneficiary raised in the name of “Sanjeevani.”  Original authorization issued by Implementing agency  Original discharge summary  Operation Note from treating Doctor (Incase of surgery)  Original Investigation and Lab Reports  List of consumables prescribed

11 Claims Flowchart Receipt of claims From NWH Communication To Hospital Claim ID Generation Document verification Medical Scrutiny and Claims Processing Approved Claims Outward Submitted To Trust (Weekly) Letter Of Settlement To he Bank By ZS Claim pending for supporting Documents Collection of DD Dispatch o hospital Complete Incomplete

12 Process of Reimbursement to NWH  Claims checked for required documents  Medical scrutiny of the Claim by TPA’s medical officers  Submission of the statement of processed claims to the ZS Management committee for release of funds.  ZSMC sanctions the release of funds  Sanction Letter submitted to the ZS Bank for DDs in the name of the Hospitals.  DDs dispatched to the Hospitals

13 Zilla Samakhaya The ZS is responsible for the day-to-day operation of the Scheme. The duties will include, Ensure service standards at provider Network for hospitalization and Diagnostics Maintaining member database Arrange for cashless treatment for the beneficiary in Network Hospital by issuing pre-authorization Claims Processing and settlement Maintenance of accounts Generation of periodic report on utilization (statistics) Administer the scheme, avoiding misuse and fraud Appoint required manpower to monitor, manage and maintain the scheme.

14 Case Manager 1.Coordinating the referral system of the patient 2.Regularly visit the Network Hospitals at least once a week and ensure that the terms and benefits of the scheme are being properly followed. 3.Interact with the beneficiaries of the scheme undergoing treatment for feedback. 4.Inform the Implementing Agency (ZS) about any non-conformance and follow-up on action taken. 5.Collate data and statistics from network hospitals on the scheme every week end and Submit it to the ZS 6.Randomly verify the operated cases for authenticity of the members. 7.Verify the authenticity of every case received for pre-authorization and submit report to ZS. The Team

15 Medical Officer Responsibility: Approval of Preauthorization based on necessity of treatment Liaison with NWH Quality monitoring of service providers

16 Data Entry Operators Responsibility: Entry of data into software Generation of reports External communication like s and letters Call center Responsibility: Attend calls and provide information to beneficiary, NWH and others Generate report on the issues and grievances

17 Accountant Responsibility: Processing Claims Preparation of bills and cash memos Preparing financial statement of the scheme Submit report for release of funds Assist the Coordinator in dealings with Bank and other financial organization

18 S.NoName of Patient ID NoAge/ Sex Addres s Specialt y Investi gation s Reports OPD Record

19 Surgery Statistics Report Date: S NoNam e ID NoAge& Sex Addr ess Date of Admis sion Name of surger y Spe cialt y Pre- autho No. Amou nt

20 OPD Statistics Weekly Report Name of the Hospital Place Statistics From: To:

21 IPD Weekly Statistics Report Name of the Hospital : District :- Surgery Statistics From: To: No. of surgeries/Medical Admissions performed for the current week

22 Details of Investigations

23 Obligations as a NWH All Network Hospitals (NWH) shall display a board with “Sanjeevani” in Telugu prominently at the reception, with white background and blue letter of eight inches size. Under the scheme, the beneficiaries are entitled to Free Out Patient services. No amount shall be collected as Registration Charges or Consultation Charges. On no account shall any amount be collected from the individual beneficiaries when admitted for surgical procedure The package rates mentioned are all exclusive of the implants and the prosthesis. The beneficiaries under the Scheme will be entitled only for General Ward Admission


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