2 Benefits of the Scheme Free OPD consultation Fixed Discount on DiagnosticsFixed discount on MedicinesHospitalization Cover for SurgeriesHospitalization Cover for Medical ConditionsWeekly consultation with lady doctor at their door stepCommunity Development ActivitiesPre existing diseases are coveredTreatment to be taken at Network Hospitals OnlyTreatment in General ward only
3 1. Out Patient Consultation PHC level: consultation with lady doctors once in a week free of costNetwork Hospital (NWH): consultation free of cost2. Diagnostics:Basic diagnostics will be done at PHC free of costDiagnostics at NWH will be done at a fixed discounted rate.3. Quality Medicines 1. Free of cost at PHC level2. 10% Discount rate at NWH3. 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 surgeriesOBG – includes normal delivery, LSCS and Hysterectomy General Surgery Gastroenterology Orthopaedics – includes fracture surgeries Genito-Urology Endocrinology ENT100% 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 5Cover would include consultation, investigation and room charges, medicines and consumables.10% of Co-Payment on the final bill.
6 PremiumFor family of 5-Rs. 260/yearAge Limit: 0-60
7 Process of Availing Treatment Beneficiary approaches VO RepresentativeVO rep explains schemeBeneficiary goes Network hospital with ID Card, ReceiptAdmission for SurgeryFree OPD ConsultationInvestigationSpecial ratesCASHLESS HospitalizationMedical treatmentPatient pays 10% of the billMember signs on the Claim FormSTARTDischargeIntimation to TPA/ZS by NWHPre-Authorization- from TPA/ZS
8 PreauthorizationWhen 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 Receive of Intimation from Hospital STARTReceive of Intimation from HospitalA-Eligibility VerificationID card, Receipt, Residential ProofB-Medical verificationNoLetter of Rejection to HospitalYesGeneration of Pre-Authorization Serial No.Data entry into SoftwareComplicated/General/ ExceptionsComplicated casesSent to VO Rep for verificationExceptionsSent to Hospital for supporting reports verificationGeneralEligibilityMedical Officer checks and fixes rateEligibleNOAuthorization letter to hospitalLetter of Rejection to HospitalSTOP
10 Claim Process The Claim Form from the Hospital should be accompanied Photocopy of the I.D. CardOriginal 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 agencyOriginal discharge summaryOperation Note from treating Doctor (Incase of surgery)Original Investigation and Lab ReportsList of consumables prescribed
11 Claims Flowchart Receipt of claims From NWH Communication To Hospital Claim ID GenerationDocument verificationMedical Scrutiny and Claims ProcessingApproved ClaimsOutwardSubmitted To Trust (Weekly)Letter Of Settlement To he Bank By ZSClaim pending for supportingDocumentsCollection of DDDispatch o hospitalCompleteIncompleteClaims Flowchart
12 Process of Reimbursement to NWH Claims checked for required documentsMedical scrutiny of the Claim by TPA’s medical officersSubmission of the statement of processed claims to the ZS Management committee for release of funds.ZSMC sanctions the release of fundsSanction Letter submitted to the ZS Bank for DDs in the name of the Hospitals.DDs dispatched to the Hospitals
13 Zilla SamakhayaThe 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 DiagnosticsMaintaining member databaseArrange for cashless treatment for the beneficiary in Network Hospital by issuing pre-authorizationClaims Processing and settlementMaintenance of accountsGeneration of periodic report on utilization (statistics)Administer the scheme, avoiding misuse and fraudAppoint required manpower to monitor, manage and maintain the scheme.
14 The Team Case Manager Coordinating the referral system of the patient Regularly visit the Network Hospitals at least once a week and ensure that the terms and benefits of the scheme are being properly followed.Interact with the beneficiaries of the scheme undergoing treatment for feedback.Inform the Implementing Agency (ZS) about any non-conformance and follow-up on action taken.Collate data and statistics from network hospitals on the scheme every week end and Submit it to the ZSRandomly verify the operated cases for authenticity of the members.Verify the authenticity of every case received for pre-authorization and submit report to ZS.
15 Medical OfficerResponsibility:Approval of Preauthorization based on necessity of treatmentLiaison with NWHQuality monitoring of service providers
16 Data Entry OperatorsResponsibility:Entry of data into softwareGeneration of reportsExternal communication like s and lettersCall centerAttend calls and provide information to beneficiary, NWH and othersGenerate report on the issues and grievances
17 AccountantResponsibility:Processing ClaimsPreparation of bills and cash memosPreparing financial statement of the schemeSubmit report for release of fundsAssist the Coordinator in dealings with Bank and other financial organization
18 Reports OPD Record S.No Name of Patient ID No Age/ Sex Address SpecialtyInvestigations
19 Surgery Statistics Report Date: S NoNameID NoAge& SexAddressDate of AdmissionName of surgerySpecialtyPre-autho No.Amount
20 OPD Statistics Weekly Report. Name of the Hospital. Place OPD Statistics Weekly Report Name of the Hospital Place Statistics From: To:
21 No. of surgeries/Medical Admissions performed for the current weekIPD Weekly Statistics Report Name of the Hospital : District :- Surgery Statistics From: To:
23 Obligations as a NWHAll 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 procedureThe 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