AB-NHPM Hospital Transaction System: Roles, Workflow, and Validation, Study Guides, Projects, Research of Project Management

Download AB-NHPM Hospital Transaction System: Roles, Workflow, and Validation and more Study Guides, Projects, Research Project Management in PDF only on Docsity!

Hospital Transaction System

TRAINING MODULE

Ayushman Bharat-National Health

Protection Mission (AB-NHPM)

AGENDA

1. Introduction

2. Pre-requisite

3. Work Flow

4. Roles and Responsibility

5. Registration

6. Validation & Authentication

7. Package Selection

8. Pre-authorisation

9. Raising Claim Request

10. Expectation from States/UTs

 (^) Computer  (^) QR Scanner  (^) Document Scanner  (^) Printer  (^) Web-cam  (^) Fingerprint Scanner/ IRIS  (^) Internet Connectivity  (^) Telephone Hardware Requirements  (^) Nominated Medical Officer as Nodal Officer  (^) Appoint Required Number of Ayushman Mitras  (^) Supporting Staff Manpower (^)  (^) Adoption of software provided by the State Health Agency (SHA)  (^) Dedicated bank accounts and books for AB-NHPM Software/ Financial

• (^) Placement of Kiosks/helpdesks at prominent places
• (^) Availability of booklets/brochures at helpdesks – to be shared with the

beneficiaries

• (^) Count of Ayushman Mitras should based on patient load Pre-requisite Hardware, Software, Manpower

Work flow - HTMS 5 BENEFICIARY NHPM ID/Aadhaar No./RSBY URN/Mobile no REGISTRATION DIAGNOSIS & ADMISSION BENEFICIARY MEDICAL CO- ORDINATOR Medical Coordinator registers patient as in-patient or out- patient based on diagnosis Medco initiates Pre-Authorization Ayushman MITRA - HOSPITAL Ayushman MITRA Submit to Doctor for Pre-authorization approval PREAUTH DOCTOR Doctor provides pre-authorization approval/reject/pending CLAIM EXECUTIVE TREATMENT, DISCHARGE BENEFICIARY MEDICAL CO- ORDINATOR Claim request submitted by Medical Coordinator CLAIMS MANAGEMENT Ayushman Mitra physically verifies the patient Claim Forwarded MEDICAL CO- ORDINATOR CLAIM DOCTOR Claim Approve/Reject / pending BALANCE CHECK PREAUTH PROCESSING

Beneficiary

visits EHCP

Beneficiary

visits EHCP

AM

AM

Validation &

Authentication

Validation &

Authentication

Regn.

Regn.

To

Medico

To

Medico



Different Process in place to cater to online/ off-line and even emergency cases



EHCP provides complete support to the beneficiary provides a guided navigation

through the facility

Registration

Beneficiary Already Verified  (^) Ayushman Mitra identifies the beneficiary’s eligibility and verification status from AB-NHPM Central Server  (^) If beneficiary is eligible and verified under AB-NHPM, server will show the details of the members of the family with photo of each verified member  (^) If verified, beneficiary can be registered for getting the cashless treatment Beneficiary Not Verified  (^) If eligible but not verified, patient will produce Aadhaar Card/ Number/ Ration Card for verification (in absence of Aadhaar)  (^) Beneficiary mobile number will be captured  (^) If Aadhaar Card/Number is available and authenticated online then patient will be verified under scheme and will be issued a AB-NHPM e-Card for getting the cashless treatment.  (^) Beneficiary gender and year of birth will be captured with Aadhaar eKYC or Ration Card Internet available Internet not available Emergency case Internet not available Emergency case

1. Internet Available Validation & Authentication

Emergency Case Record beneficiaries’ Govt. ID Card Record beneficiaries’ Govt. ID Card Record Patient’s TPIN from call Patient forgot center e-card, Aadhar Card Beneficiary pays at the time of discharge Beneficiary pays at the time of discharge Not necessary in case of emergency Beneficiary Provides e-card/Aadhar before discharge Beneficiary Provides e-card/Aadhar before discharge Internet available Internet not available Emergency case

3. Emergency Case/ Missing e-card ^ In emergency cases or if AB-NHPM e-Card/ID or Aadhaar Card/Number missing and patient claims to be AB-NHPM beneficiary and show some photo ID proof issued by Government  (^) Beneficiary may get treatment after getting TPIN (Telephonic Patient Identification Number) from the call centre and same will be recorded  (^) Government Photo ID proof need not be insisted in case of emergency  (^) In all such cases, beneficiary will provide relevant AB-NHPM proof within specified time, before discharge, otherwise beneficiary will pay for the treatment to the Hospital Validation & Authentication

 (^) EHCP can only view the packages that the EHCP is empanelled to offer under AB-NHPM  (^) Both surgical and non-surgical packages cannot be blocked together  (^) Not ore than one packages. Reduced payment shall be made in case of selection of multiple packages – as per in- built logic in software (standard insurance payment process)  (^) If for any reason treatment is not availed for any package, the operator can unblock the package before patient leaving hospital

Medico

assesses the

beneficiary

Fills clinical

details

SMS

Converts to

IP

Based on diagnosis sheet

Patient

may be

admitted

If not

changed

to OP

Diagnosis & Package Selection

 After discharge, claim would be raised to SHA through automated mail – with complete patient details

 SHA will review and release applicable payments – with reason for any applicable deduction or claim

rejection

 Upon discharge, patient will receive feedback call from call centre

 Upload all claim documents max. within 24 hours of patient discharge

Patient in IP

Daily

clinical docs

Photos

Diagnostic

reports

Upload before

discharge

Flag in case of mortality Surgical/ Medical Management

 SHA will approve or reject a claim within 15 calendar days (Turn Around Time) from the date or claim

submission

 Delay beyond 15 days (claim rejection/ approval/ investigation) will lead to imposition of 1% penalty per week

delay

 SHA may collect diagnostic reports from EHCP, at its own cost, for audit purposes, without any impact on claim

 EHCP can appeal to District Grievance Committee (DGC) to review the claim, within 30 days of claim rejection

EHCP raises claim Claim Approved Claim payment on weekly basis – transfer to bank account Claim Management Team reviews claims Medical Staff, MBBS Doctors Claim Rejection Within 15 days; Inter-state within 30 days Further Inspection Share reason for rejection Review on fortnightly basis Claim Processing