1. “Sampoorna Kutumba Arogya Pathakam” (SKAP)
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
START
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. Receive of Intimation from Hospital
START
Receive of Intimation from Hospital
A-Eligibility Verification
ID card, Receipt, Residential Proof
B-Medical verification No
Letter of Rejection to Hospital
Yes
Generation of Pre-Authorization Serial No.
Data entry into Software
Complicated/General/ Exceptions
Complicated cases
Sent to VO Rep for verification
Exceptions
Sent to Hospital for supporting reports verification
General
Eligibility
Medical Officer checks and fixes rate
Eligible NO
Authorization letter to hospital
Letter of Rejection to Hospital
STOP

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
Claims Flowchart

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. 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 ZS
Randomly 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 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
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. Reports OPD Record S.No Name of Patient ID No Age/ Sex Address
Specialty
Investigations

19. Surgery Statistics Report Date:
S No
Name
ID No
Age& Sex
Address
Date of Admission
Name of surgery
Specialty
Pre-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 week
IPD Weekly Statistics Report Name of the Hospital : District :- Surgery Statistics From: To:

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