renewal of rajiv aarogyasri health insurance scheme … · detailed list of surgeries and therapies...

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BID NOTIFICATION RENEWAL OF RAJIV AAROGYASRI HEALTH INSURANCE SCHEME FOR BPL POPULATION

IN 5 DISTRICTS OF ANDHRA PRADESH

Government of A.P. is implementing Rajiv Aarogyasri Health Insurance Scheme (Rajiv Aarogyasri-I) in all the districts of A.P. The pilot scheme (Phase-I) was launched in 3 districts on 01.04.2007 and was gradually extended to five districts in each phase (Phase-II to Phase-V) thus covering entire state. Accordingly Phase – II scheme of Rajiv Aarogyasri Health Insurance Scheme (Aarogyasri-I) which was launched on 05.12.2007 in 5 districts of West Godavari, East Godavari, Chittoor, Nalgonda and Ranga Reddy and was last renewed for one year for 352 procedures of Aarogyasri-I on 05.12.2009 is coming to end on 04.12.2010.

Government of Andhra Pradesh decided to renew the scheme for 4th year

for a period of one year from 05.12.2010 to 04.12.2011 with the following important

features in addition to other features of scheme.

Renewal of the scheme for 4th year covering 49,49,261 BPL families(as

per data furnished by Commissioner, Civil Supplies, AP on 30.08.2010)

Period of Insurance is for one year from 05.12.2010 to 04.12.2011

Bid shall be for 938 procedures of Aarogyasri-I and Aarogyasri-II The Bid Document consists of following Parts.

Part-I: Details of the Scheme

Section A - Scheme Section B - Working Pattern Section C - Aarogyamithras Section D - Packages

Part-II : MoU (Memorandum of Understanding)

Part-III : Bidding Process - General Guidelines

Part-IV : Submission of Technical and Financial Bids

Section A - General Information Section B - Technical Information Section C - Financial Bid

The Trust now invites sealed competitive bids from IRDA registered insurance

companies dealing with Health Insurance and having requisite experience as detailed

in Bid. Only the financial bids of those companies that qualify in the technical bid

scrutiny will be opened. The companies which are in agreement with the scheme

and clauses in MoU, which is an integral part of the scheme, only need to

participate in the bidding and any disagreement in this regard may invite

disqualification / rejection of bid at technical level. Hence all the companies are

requested to go through the scheme and MoU carefully and submit their agreement in

specific format given in the bid. Technical and Financial Bid documents and further

details of the scheme can be downloaded from website www.aarogyasri.org. The

completed Bid documents should be submitted before 12.00 Noon of 1st November

2010.

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SECTION-A

The salient features of Rajiv Aarogyasri Health Insurance Scheme in 5 districts of West Godavari, East Godavari,

Chittoor, Nalgonda and Ranga Reddy (Phase-II, 3rd Renewal)

1.0 Name:

The name of the scheme is Rajiv Aarogyasri Health Insurance Scheme

2.0 Objective:

To improve access of BPL families to quality medical care for treatment of

identified diseases involving hospitalization, surgeries and therapies through an

identified network of health care providers.

A) The scheme would provide coverage for 938 surgeries/therapies for

identified diseases in following systems.

1. General Surgery 2. ENT 3. Ophthalmology 4. Gynaecology & Obstetrics 5. Orthopaedics 6. Surgical Gastroenterology 7. Cardio Thoracic surgery 8. Pediatric Surgery 9. Genitourinary surgery 10. Neuro surgery 11. Surgical Oncology 12. Medical oncology 13. Radio Oncology 14. Plastic Surgery 15. Poly trauma 16. Cochlear Implantation (Refer to

clause 2.0 B of the scheme) 17. Prostheses 18. Critical care 19. General Medicine 20. Infectious Diseases 21. Paediatric Intensive Care 22. Neonatal Intensive care 23. Paediatric General 24. Cardiology 25. Nephrology 26. Neurology 27. Pulmonology 28. Dermatology 29. Rheumatology 30. Endocrinology 31. Gastroenterology

PART I

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B) Cochlear Implantation

Cochlear Implant Surgery with Auditory-Verbal Therapy for Children below 12 years

(costs to be reimbursed to Network hospital by the Trust on case to case basis and

hence not to be taken in to account for calculating the premium)

Detailed list of surgeries and therapies falling in the identified groups and packages is

given at Section–D (i) of Part – I.

3.0 Beneficiaries:

The scheme is intended to benefit below poverty line (BPL) population in the 5

districts of the State viz. West Godavari, East Godavari, Chittoor, Nalgonda and

Ranga Reddy (Phase–II, 3R). These beneficiaries are identified by Health Card/ White

ration card. Database of these families is available in ‘Health Cards’ issued by the

Trust based on the BPL ration card issued by the Civil Supplies Department. District

wise profile of the BPL families is given below:

*Based on data furnished by the Commissioner, Civil Supplies as on 30.08.2010

Note: Such of the ‘Health Card’ holders who are covered for the specified diseases by other insurance scheme such as CGHS, ESIS, Railway, RTC etc., will not be eligible for any benefit under the scheme.

4.0 Health Cards:

All eligible families in these districts are provided with Rajiv Aarogyasri Health

Cards. These Health Cards/ BPL Ration card will be basis for identification of

Beneficiary under the scheme.

4.1 Family:

Means members as enumerated and photographed on the Rajiv Aarogyasri

Health Card / BPL Ration Card. The photograph indicated in the Health Card / BPL

Ration Card will be taken as the proof for determining the eligibility of the beneficiary.

Sl.No District No. of

Families* (30.08.2010)

PHASE II

1 West Godavari 974607

2 East Godavari 1275483

3 Chittoor 907217

4 Nalgonda 861669

5 Ranga Reddy 930285

Total 49,49,261

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4.2 Enrollment:

GOAP / Trust will provide the details of each BPL family covered under the

Scheme through the Health Card/ BPL Ration Card. This Health Card / BPL Ration

Card will be a part of enrollment / identification for availing the health insurance facility.

The Insurer shall issue a tailor-made master policy to cover Surgeries / Therapies as

mentioned in clause 2 above with the following provisions:

5.0 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.

6.0 Sum Insured on Floater Basis:

The scheme shall provide coverage for meeting expenses of hospitalization and

surgical procedures of beneficiary members up to Rs.1.50 lakhs per family per year

subject to limits, in any of the network hospitals. The benefit on family will be on floater

basis i.e. the total reimbursement of Rs.1.50 lakhs can be availed of individually or

collectively by members of the family.

6.1 Servicing of Cochlear Implant Cases:

Cost for cochlear Implant Surgery with Auditory Verbal Therapy will be

reimbursed by the Trust to the Network Hospital on actual basis up to a maximum of

Rs.6.50 lakhs for each case and Insurance Company shall service the cases under the

scheme.

7.0 Buffer / Corporate Sum Insured:

An additional sum of Rs 10 Cr. shall be provided as Buffer / corporate floater to

take care of expenses; if it exceeds the original sum i.e. Rs 1.50 lakhs per

Individual/family. In such cases an amount unto Rs. 50,000/- per individual/family shall

be additionally provided on the recommendation of the committee set up by the Trust.

7.1 Automatic application of Rs.1,00,000 Buffer In case of Renal Transplant

Surgery

In case of Renal Transplant Surgery with Immunosuppressive therapy for 12

months, the buffer amount of Rs.1,00,000 (Rupees One lakh only) exclusively for this

package, will get applied automatically without formal recommendation of Technical

Committee.

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8.0 Payment of Premium:

The Trust / Government will pay the insurance premium on behalf of the BPL

beneficiaries to the Insurance Company directly in installments as agreed up on in the

MoU.

9.0 Period of Insurance

The insurance coverage under the scheme shall be in force for a period of one

year from the date of commencement of the policy (say from 00:00 hours of

05.12.2010 to midnight of 04.12.2011 for Phase-II, 3rd Renewal).

10.0 Pre and Post hospitalization

10.1 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. In case of

Kidney Transplantation the postoperative care under package has to

extend to 1 year.

10.2 Network Hospital will provide follow-up free consultation diagnostics and

medicines under follow-up packages for 125 identified procedures

provided under the scheme as annexed in Section–D(ii) of Part-I. The

package amount will be directly reimbursed to the hospital by the Trust.

11.0 Cash less Transaction

For each hospitalization the transaction shall be cashless for covered

procedures. Enrolled BPL beneficiary will go to hospital and come out without making

any payment to the hospital for the procedures covered under the scheme. The same

is the case for diagnostics if eventually the patient does not end up in doing the

surgery or therapy.

12.0 Online Claim settlement

The Insurance Company shall settle the claims of the hospitals online within 7

days of receipt of the bills along with the discharge summary and satisfaction letter of

the patient. The online progress of claim settlement will be scrutinized and reviewed by

the Trust.

13. 0 Refund

If there is a surplus after the pure claims experience on the premium (excluding

Service Tax) at the end of the policy period, after providing 20% of the premium paid

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towards the Company’s administrative cost, in the balance 80% after providing for

claims payment and outstanding claims, 90% of the left over surplus will be refunded

to the Government/Trust within 30 days after the expiry of the Run-off period. (Refer

Para No.26).

14.0 Procedure for enrollment of Hospitals:

It would be the responsibility of the Insurer for enrolment of Network Hospitals

in the State of Andhra Pradesh to give adequate facilities for the treatment of the

patients when they present themselves.

The hospitals shall be separately empanelled for this phase of the scheme.

However only those hospitals having minimum of 50 inpatient hospital beds with

adequate facilities and offering the services as stipulated below shall will be

empanelled after being scrutinized and recommended by the Empanelment and

Disciplinary Committee.

I. Definition

HOSPITAL / NURSING HOME: means any institution in Andhra Pradesh

established for indoor medical care and treatment of disease and injuries and

should be registered under APAPMCE (R&R) Act and PNDT Act (Wherever

Applicable).

II. Infrastructure and Manpower (General):

a) Should have at least 50 inpatient medical beds with adequate spacing

and supporting staff as per norms.

b) Should have Separate Male and Female General Wards.

c) Fully equipped and engaged in providing Medical and Surgical facilities

for the respective specialties.

d) In-house round the clock basic diagnostic facilities for biochemical,

Pathological and radiology tests such as Calorimeter/ Auto analyzer,

Microscope, X-ray, E.C.G, USG. etc.

e) Fully equipped Operation Theatre of its own wherever surgical operations

are carried out with qualified nursing staff under its employment round

the clock.

f) Post-op ward with ventilator and other required facilities.

g) ICU facility with requisite staff.

h) Fully qualified doctor(s) of modern medicine should be physically in

charge round the clock.

i) Casualty/duty doctor/Appropriate nursing staff.

j) Availability of Qualified/trained paramedics.

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k) Round the clock availability of specialists in the concerned specialties

and support fields within short notice.

l) Shall be able to facilitate round the clock advanced diagnostic

facilities either In-House or Tie-up facility with a nearby Diagnostic

Center.

m) Shall be able to facilitate round the clock Blood Bank facilities either

In-House or Tie-up facility with a nearby Blood Bank.

n) Shall be able to facilitate round the clock Ambulance facilities either

own or Tie-up facility with a nearby Service Provider.

o) Maintaining complete record as required on day-to-day basis and is

able to provide necessary records of the insured patient to the Insurer

or his representative as and when required.

p) Having sufficient experience in the specific identified field.

q) Shall have all necessary infrastructure required for preauthorization

round the clock.

III. Infrastructure and Manpower (Specific)

a. For Empanelment of Cancer Therapy

Services of fully qualified Medical Oncologist, Radiation Oncologist

and Surgical Oncologist – all or either and equipment for Cobalt

therapy, Linear accelerator and Brachy therapy – all or either to be

empanelled for Cancer Surgeries and Chemo and Radio-Therapies.

Note: A combination of both professional and the equipment is

essential.

b. For Empanelment of Cochlear Implant Surgery with Auditory–

Verbal Therapy:

Services of Qualified and Trained ENT Specialist in Cochlear

Implant Surgery and Auditory Verbal Therapist.

c. For Empanelment of Poly Trauma

Shall have Emergency Room Setup with round the clock dedicated

duty doctors of Modern Medicine.

Shall have round the clock anesthetist services.

Shall be able to provide round the clock services of Neuro-surgeon,

Orthopaedic Surgeon, CT Surgeon and General Surgeon, Vascular

Surgeon and other support specialties.

Shall have dedicated round the clock Emergency theatre, Surgical

ICU, Post-Op Setup with qualified staff.

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Shall be able to provide necessary cashless diagnostic support

round the clock including specialized investigations such as CT,

MRI, emergency biochemical investigations.

d. For Empanelment of Paediatric Congenital Malformations and

Post-Burns Contractures

Shall have services of qualified specialists in the field Viz., Paediatric

Surgeon, Plastic Surgeon with dedicated theatres, post-op setup and

staff.

e. For Empanelment of Prostheses (Artificial limbs)

Shall have full time services of Orthopedic Surgeon to be empanelled to

provide prostheses package under the scheme.

Shall facilitate supply, fitting of appropriate prosthesis and gait training of

patient by physiotherapist.

Shall ensure that an appropriate prosthesis is prescribed based on

occupation of the person and standard prosthesis is supplied as per

quality norms of BIS (Bureau of Indian Standards).

Shall also facilitate free replacement of leather parts and ensure total

replacement of Prosthesis in case of damage during guarantee period of

3 years.

And

IV. Hospital shall provide following additional benefit to the BPL

beneficiaries related to identified systems:

a. Provide space and separate Rajiv Aarogyasri counter/kiosk as per the

design for Aarogyamithras (Health Coordinators)

b. Provide Computer with networking (dedicated broadband with minimum 2

mbps speed), printer, webcam, scanner, bar code reader, biometrics, digital

camera and digital signatures.

c. Provide free food for the patient.

d. Provide transport / transportation charges for patient.

e. Free OPD consultation with separate Aarogyasri OP.

f. Free diagnostic tests and medical treatment required for beneficiaries

irrespective of surgery.

g. Provide the services of a dedicated Medical Officer to work as Rajiv

Aarogyasri Medical Coordinator (RAMCO) for the scheme and he will be

responsible to the Trust and the Insurer for doing various activities under the

scheme including Health Camps, Follow-up of referred patients from camps,

diagnosis, out-patient details, e-Preauthorization, Surgeries, Feedback on

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the patient’s condition and services offered by the hospital during hospital

stay of the patients, discharges, deaths if any, follow-up free consultation of

the patients and distribution of medicines after discharge etc. The Insurance

Company shall provide CUG (Closed User Groups) Connection to all

RAMCOs.

h. Provide follow-up free consultation diagnostics and medicines under follow-

up packages for 125 identified procedures annexed at Section-D (ii) of Part-

I, the package amount will be directly reimbursed to the hospital by the Trust.

i. Minimum one free Health Camp in village in a week for the screening of the

BPL patient suffering from the identified ailments. Hospital may have a

mobile team with diagnostic equipments and team of doctors as specified by

the Trust for this purpose. The Network Hospital shall do documentation and

other activities in health camps as per the health camp policy of the Trust.

Villages shall be identified by the Trust in consultation with district

administration and communicated to the hospitals/insurance company.

Hospital shall provide services of Aarogyasri Medical Camp Coordinator

(AMCCO) exclusively for organizing and coordination of health camps. The

Insurance Company shall provide CUG Connection to all AMCCOs.

14.1 MoU with network Hospital:

The Insurer shall sign MoU with all the hospitals to be empanelled under the

scheme for this Phase (Renewal). Separate MoU with the Network hospitals with

relevant provisions for Multi specialty, Cancer Treatment and Cochlear Implantation

Surgery with Auditory Verbal Therapy have to be entered into. This MoU is subject to

the approval of the Trust. Empanelled medical institutions are supposed to extend

medical aid to the beneficiary under the scheme by following guidelines issued by the

Trust from time to time. A provision will be made in MOU of non-compliance/default

clause while signing them. Such matter shall be looked in to by the Empanelment and

Disciplinary Committee consisting of members from Trust and Insurer.

14.2 Disciplinary actions against the hospitals:

On recommendation by the Empanelment and Disciplinary Committee the

Insurer shall take disciplinary actions against Network Hospital including De-listing

from the empanelment if it is found that guidelines of the Scheme are not followed by it

and services offered are not satisfactory as per laid down standards. Hospital may

also be delisted or de-empanelled if infrastructure in the hospital is found below the

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standards laid down by Trust any time during the policy period. The Insurer is also

liable for any deficiency in the service provided by the network hospital/service

provider other than medical services and in case of any delisting the Insurer shall find

an alternative immediately.

15.0 MoU with the Trust

The insurer shall enter in to the MoU with GOAP/ Trust given in Part II, which is

an integral part of the scheme within 24 hrs of award.

16.0 Non-performance

In the event of non-performance by the insurer as per the guidelines of the

scheme the insurer shall abide by the clause 18 given in the MoU given in Part II of the

document.

17.0 Standardization of formats

The Insurance Company shall standardize various formats used for cashless

transactions, discharge summary, billing pattern and other reports in consultation with

the Trust.

18.0 Implementation procedure:

The entire scheme is to be implemented as cashless hospitalization arranged

by the Insurance Company. The following table represents the process flow of

treatment to the beneficiary.

A)

Process Flow of the Beneficiary Treatment in the Network Hospital

Step 1

Beneficiaries approach nearby PHC/Area Hospitals/District Hospital/Network Hospital.

Aarogyamithras placed in the above hospitals facilitate the beneficiary. If beneficiary visits

any other PHC/Government hospital other than the Network Hospital, he/she will be given

a referral card to the Network Hospital after preliminary diagnosis by the doctors. The

Beneficiary may also attend the Health Camps being conducted by the Network Hospital

in the Villages and can get the referral card based on the diagnosis. The information on

the outpatient and referred cases in the PHC/AH/DH/NH and the camps will be collected

from all Aarogyamithras / Hospitals on a daily basis and captured in the dedicated

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database through a well-established call center.

Step 2

The first point of contact for a patient in the hospital shall be the Aarogyamithra. The

Aarogyamithras at the Network Hospital then examines the referral card and health

card/BPL ration card, registers the patients and facilitates the beneficiary to undergo

specialist consultation, preliminary diagnosis, basic tests and admission process.

Information like admission notes, tests done will be captured in the dedicated database

by the medical coordinator of the network hospital.

Step 3

The Network Hospital shall extend free OPD services in separate out-patient facility for

Aarogyasri beneficiaries by following the scheme guidelines.

Step 4

The Network Hospital, based on the diagnosis, admits the patient and sends e-

Preauthorization request to the Insurer and the Aarogyasri Health Care Trust.

Step 5

Specialists/Medical officers of the Insurer and the Trust examine the preauthorization

request and approve preauthorization if all the conditions are satisfied within 12 working

hours. However telephonic approval may be obtained in case of emergency cases to be

followed by regular pre-authorization.

Step 6

The Network Hospital extends cashless treatment and surgery to the beneficiary. Clinical

notes, operation notes / treatment schedule, postoperative notes etc., of the patients in

the Network Hospitals will be updated in the website by the Medical Coordinator.

Step 7

Network Hospital after performing the surgery/therapy forwards the original bills,

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diagnostic reports, case sheet, satisfactory letter from patient, discharge summary duly

signed by the patient, post-operative diagnostic films, videos, acknowledgement of

payment of transportation cost and other relevant documents to Insurer for settlement of

the claim. The discharge summary and follow-up details will be a part of the Trust portal.

Step 8

Insurer scrutinizes the bills and gives approval for the sanction of the bill and shall make

the payment within agreed period. The claim settlement module along with electronic

clearance and payment gateway will be part of the workflow in the Trust portal and will be

operated by the insurer. The reports shall be available for scrutiny in the Trust login.

Step 9

Network Hospital will provide follow-up free consultation diagnostics and medicines under

follow-up packages for 125 identified annexed at Section-D (ii) of Part-I, procedures

under the scheme and reimbursed by Trust

The diagram representing the working pattern is given at Section-B of Part-I.

B) New empanelment

The insurer needs to empanel the hospitals separately for this phase for specialty

services based on infrastructure available and as per the conditions laid down below:

For cancer treatment, hospitals having fully qualified professionals (Medical

Oncologist, Radiation Oncologist and Surgical Oncologist – all or either) and

equipment (Cobalt therapy Unit, Linear accelerator and Brachy therapy unit – all

or either) need to be empanelled. A combination of both professional and the

equipment is essential.

Economy protocols with packages devised by the Trust should be adhered to.

Deviations in protocol for high cost therapy beyond package will be allowed only

after scrutiny by a technical committee.

The hospital shall follow the mechanism devised to ensure that chemotherapy

drugs are physically administered, by quoting batch no., labeling of the drugs

and attaching empty vials to the bills.

The hospital should have services of Trained ENT Surgeon for Cochlear

Implant Surgery and Auditory Verbal Therapist for empanelment for Cochlear

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Implant Surgery. Separate guidelines issued in this regard by the Trust shall be

strictly adhered to.

The hospital should have full time services of qualified plastic surgeon with

requisite infrastructure for corrective surgeries for post-burn contractures.

The hospital should have full time services of Paediatric Surgeons for surgeries

for congenital malformations in children.

The hospital shall have full time services of Orthopedic Surgeon to be

empanelled to provide prostheses package under the scheme.

Hospital shall facilitate supply, fitting of appropriate prosthesis and gait training

of patient by physiotherapist.

Hospital shall ensure that an appropriate prosthesis is prescribed based on

occupation of the person and standard prosthesis is supplied as per quality

norms of BIS (Bureau of Indian Standards).

Hospital shall also facilitate free replacement of leather parts and ensure total

replacement of Prosthesis in case of damage during guarantee period of 3

years.

The conditions laid down at para 14(I),(II),(III) &(IV) above are common for all hospitals

and shall be strictly adhered to while empanelling the hospitals.

C) Packages

The insurer should ensure that the empanelled hospitals follow the packages

worked out by the Trust. The package includes consultation, medicine, diagnostics,

implants, food, cost of transportation, hospital charges etc. In other words the package

should cover the entire cost of patient from date of reporting to his discharge from

hospital 10 days after surgery, making the transaction truly cashless to the patient.

D) Health Camps

Health Camps are to be conducted in all Mandal Head Quarters, Major

Panchayats, Municipalities and villages. The insurer should ensure that at least one

free medical camp is conducted by each network hospital in a week at the place

suggested by the Trust. The Aarogyasri Medical Camp Coordinator of the Hospital

shall coordinate the entire activity. They should carry necessary screening equipment

along with specialists (as suggested by the Trust) and other paramedical staff. They

should also work in close liaison with District Coordinator, DM & HO in consultation

with District Collector. The Hospital shall follow the camp policy of the Trust.

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E) District Level Coordination

District level offices with necessary infrastructure have to be set-up by the

Insurance Company. The Insurer needs to have district level monitoring staff with

district coordinators and regional coordinators (in charge of a group of Mandals within

the district). GMs/DGMs/Area Managers/Assistant Area Managers / District

Coordinators / Regional Coordinators / District Coordinators / District level doctors /

Regional coordinators of the insurance company should monitor Aarogyamithras,

coordinate with network hospital, district administration and people’s representatives

for effective implementation of programme. They should ensure that camps are held

as per schedule, arrange for canvassing for the camp, mobilize patients and follow up

the beneficiaries.

He / She should work in close liaison with district administration under the supervision

of district collector. He should also ensure proper flow of MIS and report to Trust on

day-to-day basis about the progress of the scheme in the district. The company should

ensure that dedicated staff is made available for the scheme. There shall be at least

one doctor to be placed in each district. Further wherever the concentration of the

network hospitals is more additional doctors need to be placed. The entire operation in

the field should be monitored by a dedicated department called Field Operations

Support Services (FOSS) at Project Office. Performance of all the field functionaries

and the staff and managers in project office shall be assessed periodically with definite

performance appraisal system and KPIs. The Insurance Company shall follow the

instructions of the Trust in this regard.

19.0 Aarogyamithras

a. Aarogyamithras in PHCs/ CHCs/ Area Hospitals/ Government

Hospitals etc: The unique nature of the scheme demands the

insurance company to appoint Aarogyamithras in consultation with

the Trust in all PHCs, CHCs, Area Hospitals and District Hospitals for

propagating the scheme, mobilizing people for health camps,

counseling beneficiaries, facilitating the referral/treatment of these

patients and follow-up. For effective and instant communication all

the Aarogyamithras will have to be provided with cell phone CUG

connectivity by the Insurance Company.

b. Aarogyamithras in Network Hospitals: The Insurance Company

also needs to appoint at least three Aarogyamithras at all network

hospitals to facilitate admission, treatment and cashless transaction

of patient round the clock. The Aarogyamithras should also help

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hospitals in pre-auth, claim settlement and follow-up. They should

also ensure proper reception and care for the patient in the hospital

and send regular MIS. Insurance Company shall provide all

Aarogyamithras with cell phone having CUG connectivity with SMS

based reporting framework for effective and instant communication.

The insurance company shall ensure that prefabricated

Aarogyamithra kiosks with all additional requirements as per the

design approved by the Trust is put up in all hospitals. The role of

Aarogyamithras can be modified by the Trust from time-to-time.

The insurer will provide uniform and arrange the workshops/training sessions for the

Aarogyamithras on the guidelines specified by the Trust. Performance of the

Aarogyamithras both in PHCs and Network Hospitals shall be assessed periodically

with definite performance appraisal system and KPIs. Section–C of Part-I deals with

the details on Aarogyamithras and their role.

20.0 Online MIS and 24 Hour e-Preauthorization

The Insurance Company should post enough dedicated staff, so as to ensure

free flow of daily MIS and ensure that progress of scheme is reported to Trust in the

desired format on a real-time basis. The company should establish proper networking

for quick and error-free processing of pre-authorizations. This will be done through the

existing dedicated website of the Trust, the up gradation and maintenance cost of the

software, hardware, connectivity and data center will be borne by the Insurance

Company. The pre-authorization has to be done round- the-clock in coordination with

Trust i.e., by a team of doctors from the Trust and the Insurance Company. The

preauthorization team shall have all the specialists concerned with the systems

covered in the scheme on a permanent basis. The Trust will provide necessary

specialists and technical committees to evaluate special cases from time-to-time. The

website will be a repository of information and will have the following features:

1. General Information on the scheme.

2. Details of patients reporting and referrals from the PHC/CHC/Government

Hospitals/ District hospitals on daily basis

3. e-Health Camps system and daily reporting of health camps.

4. Details of patients reporting and getting referred from the health camps.

5. e-Empanelment system.

6. Emergency approval system

7. Call centre application.

8. Patient registration by Aarogyamithra in Network Hospitals

9. Details of in-patients and out patients in the network hospitals

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10. On-bed reporting system.

11. Costing of the Tests done in the network hospitals

12. e-preauthorization.

13. Surgery details.

14. Discharge details.

15. Real-time reporting, active data warehousing and analysis system.

16. Claim settlement

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. e-Office management

25. Accounting system

26. TDS workflow.

27. Death reporting system.

28. Biometrics and Digital Signatures

29. Analytical tools including BI

21.0 Medical Auditors

The company should appoint enough number of medical officers and specialists

who does pre-authorization in consultation with Trust. The Company shall also recruit

specialized doctors for regular inspection of hospitals, attend to complaints from

beneficiaries directly or through Aarogyamithras for any deficiency in services by the

hospitals and also to ensure proper care and counseling for the patient at network

hospital by coordinating with Aarogyamithras and hospital authorities.

22.0 In-House System

The Insurance Company has to establish in-house system to provide all such

facilities elaborated under the scheme and MoU.

23.0 Publicity

The insurance company on its part should ensure that proper publicity is given

to the scheme. It should print brochures, banners, display boards in public places and

highways. They should effectively use services of Aarogyamithras and field staff for

this purpose.

24.0 State Level Coordination

The company should nominate responsible officer/ officers to properly

coordinate above work and ensure proper implementation of scheme up to the

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satisfaction of Trust. They should review the progress with Trust on day-to-day basis

and be responsible to implement the suggestions of Trust for effectively running the

scheme. The Project Office of the Insurance Company shall be separately established

at a place desired by the Trust for better coordination. The project office shall report to

the Trust on a daily basis in the prescribed proformas. The following departments shall

be established by the Insurance Company in the Project Office:

i) 24 hour call center with toll free help line and online workflow.

ii) Field Operations Support Services (FOSS) Department to coordinate

the daily activities with dedicated executives and managers for each

district monitoring field staff in each district consisting of Aarogyamithras,

Regional Coordinators, Team Leaders, Assistant Area Managers, Area

Managers, Deputy General Managers, General Mangers.

iii) MIS Department to collect, collate and report data on a real-time basis.

This department will also have a subunit with operators who collect

hourly information from the Aarogyamithras, Regional Coordinators,

Team Leaders, Assistant Area Managers, Area Managers, Deputy

General Managers, General Mangers etc. Based on this the reverse flow

of dissemination of information shall also take place. There shall be

subunits for each district. The MIS department shall also follow-up the

cases at all levels. The department shall also generate reports as

desired by the Trust. The department should have capability to analyse

the data on real time basis. They shall also use BI tools and other

statistical frame works for continuous monitoring and shall coordinate

with all other departments.

iv) HR Department to manage human resources for the scheme.

v) Training Department for capacity building of all stakeholders and staff.

vi) IT Department to ensure that the website with e-preauthorization, claim

settlement and real-time follow-up is maintained and updated on a 24-

hour basis.

vii) Round-the-Clock Pre-authorization Department with specialist

doctors for each category of diseases shall work round the clock along

with the Trust doctors to process the preauthorization within 12 working

hours. The doctors shall also undertake inspection of hospitals.

viii) Claims settlement Department with electronic clearance facilities.

ix) Health Camp Department to plan, intimate, implement and follow-up the

camps as per the directions of the Trust.

18

x) Publicity and logistics Department to undertake all the publicity and

logistics activities as specified by the Trust.

xi) Grievance Department to be manned by doctors and other staff to

address the grievances from time to time as per the instructions of the

Trust.

xii) Follow-up Department to coordinate the follow-up consultation and

distribution of drugs as per the instructions of the Trust.

xiii) Empanelment department to empanel the hospitals in the network as

per the guidelines given by the Trust and monitor the compliance.

xiv) Feedback Department to 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.

xv) Administration Department for office management.

xvi) Vigilance Department for keeping vigil on all service providers and staff.

xvii) Legal Department exclusively for the project.

xviii) Accounts Department.

xix) Other departments required for Office work.

The company shall operate the above departments with definite hierarchy (Executive,

Assistant managers, Managers, DGMS, GMs, Project Officer etc.,) through e-office

module for efficient, transparent and paperless office with above departments.

25.0 Capacity Building

The insurer will arrange the workshops / training sessions for the capacity

building of the insured, their representatives and other stakeholders in respect of the

scheme and their roles at each district on the convenience of the insured and other

stake holders. The insurer shall undertake the following training programmes for

stakeholders.

Empanelment training programme

Network Hospital training programme at hospital

Network hospital reorientation programme

Induction programme

PHC Aarogyamithras training programme

Training Programme for Field functionaries

Soft & Communication skills training programme

Any other training and orientation programme designed by the Trust

19

26.0 Run-off Period

A Run-off period of one month will be allowed after the expiry of the policy. This

means that pre-authorizations can be done till the end of policy period and surgeries

for such pre-authorizations can be done up to one month after the expiry of policy

period and all such claims will be honoured.

27.0 Aarogyasri Manual

The Trust has published a detailed Manual for the Scheme titled ‘Rajiv

Aarogyasri Manual’ consisting of all the operational guidelines and details of the

scheme. This manual has been updated with fresh guidelines. Trust may update and

modify these guidelines and operational details as per the requirement of the scheme.

The Insurer has to follow the guidelines and instructions given in the manual while

implementing the scheme.

20

SECTION- B Working Pattern

21

SECTION-C AAROGYAMITHRA

Aarogyasri is a unique PPP model Health Insurance Scheme tailor made to

meet the out of pocket health expenditure requirement of BPL families for

identified diseases. The scheme was introduced with the guiding principle that

insurance schemes should be targeted at catastrophic illnesses and the benefit

in the primary care should be addressed through free screening and outpatient

consultation. The government health system combined with Aarogyasri is able

to meet the entire health requirements of population in the state. The scheme is

implemented through effective use of IT based solution which is unique to the

scheme in reaching out to the beneficiary. The scheme has many unique

features to its credit to proactively reach beneficiary and guide him to avail the

services in a cashless manner.

1. Aarogyamithras (Facilitator services)

2. Round the clock Call Centre with Toll free help line.

3. Health Camps conducted by network hospitals.

4. Follow up by elaborate field mechanism.

5. End-to-end cashless packages.

6. Services of RAMCO (Rajiv Aarogyasri Medical Coordinator) and

AMCCO (Aarogyasri Medical Camp Coordinator) in the network

hospitals.

7. CUG (Closed User Group) connectivity to all the field staff, RAMCO

and AAMCO.

8. Placement of Aarogyasri kiosk with Network connectivity.

9. Robust IT based solution, capturing patient details right from the

reporting to the claim settlement and follow up.

10. Social auditing through feedback letter from the beneficiary and

Prajapatham programme.

Since the scheme is very unique and having no parallels anywhere in the

country, Trust included a strong facilitation mechanism under the scheme to not

only guide the beneficiary right from his door step but also to create awareness

among rural illiterate poor for effective implementation. Further it was

contemplated that the facilitator may be selected among the local populace for

effective communication among these rural poor. Accordingly, the concept of

‘Aarogyamithra (The friend of Health)’ was evolved and the organized structure

of rural self help groups (SHG) in the state was effectively used to select and

22

train these facilitators. A detailed note on the Aarogyamithra services is given

below.

1. Aarogyamithra is Friend of Health. Aarogyamithra is a concept unique to

Rajiv Aarogyasri Health Insurance Scheme. Aarogyamithras act as

facilitators for the patients. In fact they form face of this scheme in the

villages and in the network hospitals.

2. There are two categories of Aarogyamithras

i. Aarogyamithras with PHC’s/AH’s/CHC’s/District Hospitals

ii. Aarogyamthras with Network Hospitals

3. (i) Aarogyamithras with PHC’s/AH’s/CHC’s/District Hospitals

Aarogyamithras are to be selected by the stakeholders of Self Help Group

(SHG) movement/ Indira Kranthi Patham from local area of each PHC /

Government Hospital in order to ensure performance efficiency and

acceptability among local communities. The following qualifications are

mandatory.

i) Graduate

ii) Native & Resident of the same PHC area

iii) Good communication skills

iv) Prefers to move around the villages

v) Functional knowledge of computers

The Mandal and Zilla Samakhya (Federation of SHGs at Mandal & District level)

are the nodal agencies that select the Health Coordinators (Aarogyamithras).

Insurance company has to enter into an MOU with the Zilla Samakhya to hire

the services of local persons in each PHC/CHC/Area Hospital/Government

Hospital. The Insurance Company will make a consolidated payment for the

Health Coordinators through the Zilla Samakhya. The working of the

Aarogyamithras will be monitored on a daily basis by the District Coordinator of

the Trust,Regional Coordinators and Area Managers of the Insurance Company

in coordination with the Zilla / Mandal samakhyas, District Rural Development

Agency, DM & HO, District Administration etc. All the Aarogyamithras are

provided with cell phones (CUG connection) by the Insurance Company for

instant communication and networking. The Insurance Company also provide

uniforms (Aprons) for all Aarogyamithras.

(ii) Aarogyamithras with Network Hospitals:

Apart from the Aarogyamithras in PHC/CHC/Area Hospitals/District Hospitals

the Insurance Company has to select and post at least three Aarogyamithras in

23

each Network Hospitals under the scheme for round the clock monitoring of the

patients. The total number will depend up on the exact number of the Network

Hospitals. The Insurance Company follow the instructions of the Trust in this

regard.

4. Training of Aarogyamithras

Training for Aarogyamithras is being done by the Trust and Insurance Company.

The concept, content and training material is prepared by the Trust.

The following table shows the indicative number of PHC’s / Government Hospitals

where Aarogyamithras are to be placed:

District

E.Godavari

W.Godavari Chittoor RangaReddy Nalgonda Total

No. of PHCs 84 68 91 41 72 356

No. of CHCs (30 beds)

08 06 10 10 07 41

No. of Area Hospitals

03 02 03 01 04 13

No. of District Hospitals

01 01 01 01 01 5

Total 96 77 105 53 84 415

In addition to the above the Insurance Company has to select and post at least three

Aarogyamithras in each Network Hospitals for round the clock monitoring of the

patients. The total number will depend up on the exact number of the Network

Hospitals. The Insurance Company shall follow the instructions of the Trust in this

regard.

Role of Aarogyamithras in PHC/CHC/Area Hospital / District hospitals

a) IN THE PHC

Publicity and awareness.

Maintain helpdesk at hospital.

Receive the beneficiary.

Verify the Beneficiary criteria. (Eligibility Criteria)

Facilitate consultation with Doctor (PHC Doctor/Nearest Govt.

Hospital Doctor).

Fill up the referral card.

Guide the patient to the next center.

To counsel the patients who may require any one of the listed

surgeries.

24

To facilitate either to a Government Hospital for further tests or to a

Network Hospital depending upon the advice of the doctor.

To guide the patient to Network Hospital.

Follow-up the referred cases.

In effect to act as, a guide and friend for all the beneficiaries under the

Aarogyasri Sri scheme.

Any work assigned by the Trust from time to time.

b) OUTSIDE THE PHC

To send daily MIS of the patients

To spread the awareness of the scheme in the villages.

To spread the awareness about the scheduled camps by network

hospitals in the villages.

To coordinate with network hospitals and help conduct camps.

Mobilize the patients for camps.

Conducting health camps along with doctors from network hospitals

and local Medical Officer. People with all ailments are screened in

these camps and are given drugs free of cost.

Follow up the patients identified in the camp to report to network

hospital.

Coordinate with local PR Bodies, Village organizations (Vos),

Samakhyas, ANMs, Women Health Volunteers and Self-Help Groups

for effective implementation of the scheme.

Move around the villages and encourage patients to come to avail the

benefits of the scheme.

Educate villagers about the scheme and distribute brochures and

other material.

Report to the Regional Coordinator, Assistant Area Manager, Area

Manager.

Follow up the Beneficiaries before and after Surgery / Treatment.

To report deaths related to the scheme.


2) ROLE OF AREA HOSPITAL/CHC/DISTRICT HOSPITAL

AAROGYAMITHRAS

Apart from the duties enlisted above the Aarogyamithras in Area Hospital

and District Hospitals will

Facilitate the Patient for specialist consultation and tests

Fill up the referral card (part-B) properly

25

Counsel the patient


3) ROLE OF AAROGYAMITHRAS AT NETWORK HOSPITAL

Maintain Help Desk at Reception of the Hospital.

Receive the patient referred from (PHC or Network)

Work round the clock in shifts to cater to the needs of

emergencies

Verify the health card / documents of the patients.

Obtain digital photograph of the patient.

Facilitate the Patient for consultation and admission.

Liaison with coordinator/administration of the hospital.

Counsel the patient regarding treatment/surgery.

Facilitate early evaluation and posting for surgery.

Facilitate hospital send proper pre-authorization.

Follow-up preauthorization procedure and facilitate approval.

Follow-up recovery of patient.

Facilitate payment of transport charges as per the guidelines.

Facilitate cashless transaction at hospital.

Facilitate discharge of the patient.

Obtain feedback from the patient.

Counsel the patient regarding follow-up.

Coordinate with PHC/Government Hospital Aarogyamithras for

follow-up of beneficiary.

Follow-up the patient referred by the hospital during the camps.

Coordinate with the Head-Office and Medical officers for any

clarifications.

Send daily MIS

Facilitate Network Hospital in conducting Health Camps as

scheduled.

To report deaths related to the scheme.


Performance of the Aarogyamithras both in PHCs and Network Hospitals shall be

assessed periodically with definite performance appraisal system and KPIs through e-

office. The Insurance Company shall follow the instructions of the Trust in this regard.

26

SECTION-D

PACKAGES GENERAL GUIDELINES ON PACKAGES.

1. The package includes

Screening

Consultation, medicines, diagnostics, specialist services

Implants, grafts, prosthetics,

Food,

Cost of transportation

Hospital charges etc. In other words the package should cover the entire cost of treatment of the patient from patient screening, date of reporting in the hospital to his discharge from hospital and 10 days after discharge and any complications while in hospital, making the transaction truly cashless to the patient. The post-operative hospital stay in all surgical procedures shall be minimum of 10 days except in case of interventions and chemotherapy for cancers.

2. Hospital shall conduct all diagnostic tests as per standard protocols free of cost. 3. Hospital shall provide 10 days post discharge free medicines to the patient

within package. 4. Hospital shall provide reasonably good food to the patient, and shall make

alternate arrangement for food wherever in-house pantry is not available. The hospital shall not give money as an alternative to food.

5. Hospital shall pay return fare from Mandal Headquarters to the town where hospital is situated based on RTC fare. Minimum of Rs.50 shall be provided and thereafter it shall be on the basis of distance.

6. Hospital shall assist and facilitate the patient to procure compatible blood for the surgeries. The hospital shall provide blood from its own blood bank subject to availability within the package. In case of non-availability the hospital shall make efforts to procure from other blood banks, Red Cross, voluntary organizations etc., The hospital shall also issue a copy of the request letter to the patient.

7. The general guidelines published by the Trust separately from time to time shall be followed while implementing the packages.

(i) PACKAGE RATES

SURGICAL PACKAGES

S.No. Code SYSTEM PACKAGES

S1 GENERAL SURGERY

S1.1 HEAD & NECK

S1.1.1 Neck

1 S1.1.1.1 Branchial Cyst Excision 20000

2 S1.1.1.2 Branchial Sinus Excision 20000

3 S1.1.1.3 Carotid Body-tumours Excision 30000

4 S1.1.1.4 Cystic Hygroma Excision-Extensive 20000

5 S1.1.1.5 Cystic Hygroma Excision-Major 20000

6 S1.1.1.6 Cystic Hygroma Excision-Minor 10000

7 S1.1.1.7 Excision of Lingual Thyroid 25000

8 S1.1.1.8 Parathyroidectomy 30000

9 S1.1.1.9 Excision of Thyroglossal Cyst- 20000

27

Fistula

10 S1.1.1.10 Cervical Rib excision 15000

11 S1.1.1.11

Removal of Submandibular

10000 Salivary gland

12 S1.1.1.12 Parotid Duct Repair 20000

S1.1.2 Mandible

13 S1.1.2.1 Hemimandibulectomy 25000

14 S1.1.2.2 Segmental Mandible Excision 25000

S1.1.3 Tounge

15 S1.1.3.1 Partial glossectomy 15000

S1.1.4 Lip

16 S1.1.4.1 Abbe Operation 15000

17 S1.1.4.2 Vermilionectomy 15000

18 S1.1.4.3 Wedge Excision& Vermilionectomy 20000

19 S1.1.4.4 Wedge Excision 15000

S1.1.5 Thyroid (Non-Malignant )

20 S1.1.5.1 Hemithyroidectomy 20000

21 S1.1.5.2 Isthmectomy 20000

22 S1.1.5.3 Partial Thyroidectomy 20000

23 S1.1.5.4 Resection Enucleation 20000

24 S1.1.5.5 Subtotal Thyroidectomy 20000

25 S1.1.5.6 Total Thyroidectomy 20000

S1.2 BREAST

26 S1.2.1 Simple Mastectomy(NM) 25000

S1.3 ABDOMEN

S1.3.1 Hernia

27 S1.3.1.1 Epigastric Hernia without Mesh 20000

28 S1.3.1.2 Epigastric Hernia with Mesh 30000

29 S1.3.1.3 Femoral Hernia 20000

30 S1.3.1.4

Hiatus Hernia Repair

40000 Abdominal

31 S1.3.1.5

Rare Hernias (Spigalion,

20000 obuturator,sciatic)

32 S1.3.1.6 Umbilical Hernia without mesh 20000

33 S1.3.1.7 Umbilical Hernia with mesh 30000

34 S1.3.1.8 Ventral and Scar Hernia without mesh 20000

35 S1.3.1.9 Ventral and Scar Hernia with mesh 30000

S1.3.2 Appendix

36 S1.3.2.1 Lap. Appendicectomy 22000

37 S1.3.2.2 Appendicular Perforation 20000

S1.3.3 Stomach, Duodenum and Jejunum

38 S1.3.3.1

Highly Selective

25000 Vagotomy

39 S1.3.3.2

Selective Vagotomy

40000 Drainage

40 S1.3.3.3 Vagotomy Pyloroplasty 40000

41 S1.3.3.4

Gastrojejunostomy &

40000 Vagotomy

42 S1.3.3.5

Operation for

40000

bleeding peptic

Ulcer

43 S1.3.3.6

Partial/subtotal

40000 Gastrectomy for ulcer

44 S1.3.3.7 Pyloromyotomy 20000

45 S1.3.3.8 Gastrostomy 20000

46 S1.3.3.9 Gastrostomy Closure 20000

47 S1.3.3.10 Duodenal perforation 40000

28

S1.3.4 Small Intestine

48 S1.3.4.1 Intususception 40000

49 S1.3.4.2

Operation for

40000 Acute intestinal obstruction

50 S1.3.4.3

Operation for

40000 Acute intestinal perforation

51 S1.3.4.4

Operation for

40000

Haemorrhage of the

small intestine

52 S1.3.4.5

Operations for Recurrent intestinal

40000 obstruction (Noble plication other)

53 S1.3.4.6

Resection & Anastomosis

35000 of small intestine

54 S1.3.4.7 Ileostomy 20000

55 S1.3.4.8 Ileostomy Closure 20000

S1.3.5 Large Intestine

56 S1.3.5.1

Mal-rotation & Volvulus of the

40000 Midgut

57 S1.3.5.2

Operation for Volvulus

40000 of large bowel

58 S1.3.5.3

Operation of the Duplication of the

40000 Intestines

59 S1.3.5.4

Left Hemi-

30000 Colectomy

60 S1.3.5.5

Right Hemi

30000 Colectomy

61 S1.3.5.6 Total Colectomy 40000

62 S1.3.5.7 Colostomy 20000

63 S1.3.5.8 Colostomy Closure 20000

S1.3.6 Rectum and Anus

64 S1.3.6.1

Pull through abdominal

30000 Resection

65 S1.3.6.2 Anterior Resection 50000

S1.4 Liver

66 S1.4.1

Operation for

30000

Hydatid cyst of

Liver

67 S1.4.2 Portocaval Anastomosis 80000

S1.5 Gallbladder

68 S1.5.1 Cholecystectomy 20000

69 S1.5.2 Lap.Cholecystectomy 35000

70 S1.5.3 Cholecystectomy & Exploration CBD 35000

71 S1.5.4 Cholecystostomy 25000

72 S1.5.5 Cystojejunostomy 40000

73 S1.5.6 Cystogastrostomy 40000

74 S1.5.7 Repair of CBD 40000

S1.6 Adrenals

75 S1.6.1

Operation of Adernal

40000 glands, bilateral for tumor

76 S1.6.2 Operation on Adrenal glands unilateral for tumour 25000

S1.7 Spleen

77 S1.7.1

Splenectomy for

35000 Hypersplenism

78 S1.7.2

Splenorenal

60000 Anastomosis

79 S1.7.3 Warren shunt 60000

29

S2 ENT SURGERY

S2.1 EAR

80 S2.1.1 Labyrinthectomy 20,000

81 S2.1.2

Facial Nerve

20,000 Decompression

82 S2.1.3

Temporal

50,000 Bone Excision

S2.2 THROAT

83 S2.2.1

Microlaryngeal

12,000 Surgery

84 S2.2.2 Phono Surgery for Vocal cord paralysis 25,000

85 S2.2.3 Laryngo Fissurectomy 20,000

86 S2.2.4 Exision of Tumors in Pharynx 20000

87 S2.2.5 Parapharyngeal tumour Excision 20000

88 S2.2.6 Adenoidectomy + Gromet insertion 10000

89 S2.2.7 Uvulo-palato-Pharyngoplasty. 25000

S2.3 NOSE

90 S2.3.1 Endoscopic sinus surgery 15000

91 S2.3.2 Mastoidectomy 15000

92 S2.3.3 Tympanoplasty 15000

93 S2.3.4 Stapedectomy + Veingraft 15000

94 S2.3.5 Excision of Benign Tumour Nose 15000

95 S2.3.6 Angiofibroma Nose 40000

96 S2.3.7 Endoscopic DCR 20000

S2.4 FOREIGN BODY REMOVAL (BRONCHUS/OESOPHAGUS)

97 S2.4.1 Bronchoscopy foreign body removal 20000

S3 OPTHALMOLOGY SURGERY

S3.2 CORNEA and SCLERA

98 S3.2.1 Therapeutic Penetrating Keratoplasty 15000

99 S3.2.2 Lamellar Keratoplasty 3000

100 S3.2.3 Corneal Patch Graft 4000

101 S3.2.4 Scleral Patch Graft 6000

102 S3.2.5 Penetrating Keratoplasty 15000

103 S3.2.6 Double Z-Plasty 4000

104 S3.2.7 Amniotic Membrane Graft 7000

S3.3 VITREO-RETINA

S3.3.1 VITREA

105 S3.3.1.1 VITRECTOMY 6000

106 S3.3.1.2

Vitrectomy + Membrane peeling+ Endolaser , silicon oil or gas + with or without belt buckling. 30000

107 S3.3.1.3 Vitrectomy + Membrane peeling+ Endolaser 25000

108 S3.3.1.4 Vitrectomy + silicon oil or gas 20000

109 S3.3.1.5 Removal of silicon oil or gas 6000

110 S3.3.1.6 Monthly Intravitreal Anti-VEGF for macular degeneration / Per injection (maximum - 6) 7000

S3.3.2 RETINA

111 S3.3.2.1 Scleral buckling for Retinal detachment 15000

112 S3.3.2.2 Photocoagulation for Retinopathy /per sitting 1500

S3.4 ORBIT

113 S3.4.1 SOCKET RECONSTRUCTION 7000

114 S3.4.2 DERMIS FAT GRAFT 9000

115 S3.4.3 ORBITOTOMY 10000

30

116 S3.4.4 Enucleation/Evisceration with orbital Implant 20000

117 S3.4.5 Decompression / Excision of Optic nerve lesions* 65000

118 S3.4.6 Proptosis* 60000

S3.5 SQUINT CORRECTION SURGERY

119 S3.5.1 Rectus Muscle Surgery(Single) 6000

120 S3.5.2 Rectus Muscle Surgery(Two/Three) 12000

121 S3.5.3 Oblique Muscle 6000

S3.6 LID SURGERY

122 S3.6.1 Lid reconstruction Surgery- 15000

123 S3.6.2 Ptosis* 25000

S3.7 PEDIATRIC OPHTHALMIC SURGERY

124 S3.3.6 Photocoagulation for Retinopathy of prematurity 7500

125 S3.3.7 Paediatric Catract Surgery(Phacoemulsification+IOL) 15000

126 S3.3.8 Glaucoma filtering Surgery for Paediatric Glaucoma 15000

S4 GYNAECOLOGY AND OBSTETRICS SURGERY

S4.1 Obstetrics

127 S4.1.1 Caesarean Hysterectomy with Bladder Repair 30,000

128 S4.1.2

Rupture Uterus with

25,000 Tubectomy

129 S4.1.3 Eclampsia with Complications requiring ventilatory support 20000

130 S4.1.4 Abruptio-placenta with Coagulation Defects(DIC) 20000

S4.2 Gynaecology

131 S4.2.1 LAVH 30,000

132 S4.2.2 Laparoscopic Cystectomy 20,000

133 S4.2.3 Laparoscopic Ectopic Resection 20,000

134 S4.2.5 Laparoscopic Myomectomy 25,000

135 S4.2.6 Laparoscopic recanalisation 20,000

136 S4.2.7 Laparoscopic Sling operations 25,000

137 S4.2.8 Laparoscopic adhesolysis 25,000

138 S4.2.9 Vaginal Hysterectomy 20,000

139 S4.2.10

Vaginal Hysterectomy with

30,000 pelvic floor repair

140 S4.2.12

Cystocele ,Rectocele &

20,000 Perineorraphy

141 S4.2.14

Mc Indo's repair for

30,000 Vaginal Atresia

142 S4.2.16 Vault prolapse abdominal repair 30,000

143 S4.2.17 Vault prolapse abdominal repair with mesh 40,000

S5 ORTHOPEDIC SURGERY AND PROCEDURES

S5.1 Fracture Correction Surgeries/Procedures

144 S5.1.1 Bone Grafting as exclusive procedure 20,000

145 S5.1.2 Excision or other Operations for Scaphoid Fractures 15,000

146 S5.1.3

Open Reduction & Internal Fixation of Fingers & [email protected] each up to a maximum of Rs.15000 Up to 15000

147 S5.1.4 Reduction of Compound Fractures & External fixation 15,000

148 S5.1.5 ILIZAROV Ring Fixator Application 40,000

31

149 S5.1.6 CTEV Neglected - JESS Fixator 30,000

S5.2 Dislocations

150 S5.2.1 Open Reduction of Dislocations – Deep 30,000

S5.3 Amputations (Non-Traumatic)

151 S5.3.1 Amputations – Forequarter 30,000

152 S5.3.2 Amputations - Hind Quarter and Hemipelvectomy 40,000

S5.4

Bone and Joint Surgery & Osteotomy Procedures including post-polio and cerebral palsy corrections

153 S5.4.1 Arthrodesis of - Major Joints 30,000

154 S5.4.2 Arthroscopy – Diagnostic 20,000

155 S5.4.3 Arthroscopy - Operative Meniscectomy 25,000

156 S5.4.4 Arthroscopy - ACL Repair 30,000

157 S5.4.5 Avascular Necrosis of Femoral Head (core decompression) 15,000

158 S5.4.6 Soft Tissue Reconstructive Procedures for Joints / osteotomies Up to 30,000

S5.5 Spine Surgery

159 S5.5.1 Anterolateral Clearance for Tuberculosis 50,000

160 S5.5.2 Costo Transversectomy 30,000

161 S5.5.3 Spinal Ostectomy and Internal Fixations 40,000

S5.6 Soft Tissue Surgery

162 S5.6.1 Nerve Repair with Grafting 30,000

163 S5.6.2 Neurolysis/Nerve Suture 25,000

164 S5.6.3 Operations for Brachial Plexus & Cervical Rib 30,000

S5.7 TUMOR SURGERY

165 S5.7.1 Excision of Bone Tumours - Deep with re-construction with conventional prosthesis 40,000

S6 SURGICAL GASTROENTEROLOGY

S6.1 Emergency

166 S6.1.1 Surgery for Bleeding Ulcers 40000

167 S6.1.2 Surgery for Obscure GI Bleed 60000

S6.2 Oesophagus

168 S6.2.1 Colonic Pull up 30000

169 S6.2.2 Oesophagectomy 60000

170 S6.2.3 Oesophago-Gastrectomy 75000

171 S6.2.4 Lap Heller's myotomy 30000

172 S6.2.5 Lap Fundoplications 45000

S6.3 Stomach

173 S6.3.1 Partial Gastrectomy 40000

174 S6.3.2 Total Gastrectomy 40000

175 S6.3.3 Truncal vagotomy + Gastro Jejunostomy 40000

176 S6.3.4 Distal Gastrectomy for Gastric Outlet obstruction 40000

177 S6.3.5 Surgery for Corrosive injury Stomach 50000

S6.4 Small Intestine

178 S6.4.1 Volvulus 40000

179 S6.4.2 Malrotation 40000

180 S6.4.3 Lap Adhesiolysis 40000

S6.5 Large Intestine

181 S6.5.1 Right Hemicolectomy 30000

182 S6.5.2 Left Hemicolectomy 30000

183 S6.5.3 Extended Right Hemicolectomy 35000

184 S6.5.4 Anterior Resection 40000

185 S6.5.5 Anterior Resection with Ileostomy 50000

186 S6.5.6 Abdomino Perineal Resection(Non-Malignant) 50000

32

187 S6.5.7 Hartman's Procedure with Colostomy 45000

S6.5.8 Ulcerative Colitis

S6.5.8.1 III Stage Procedure

188 S6.5.8.1.1 I Stage-Sub Total Colectomy + Ileostomy 50000

189 S6.5.8.1.2 II Stage-J – Pouch 30000

190 S6.5.8.1.3 III Stage-Ileostomy Closure 20000

S6.5.8.2 II Stage Procedure

191 S6.5.8.2.1 I Stage- Sub Total Colectomy + Ileostomy + J – Pouch 80000

192 S6.5.8.2.2 II Stage- Ileostomy Closure 20000

S6.6 Liver:

193 S6.6.1 Hepato Cellular Carcinoma(Advanced) Radio Frequency Ablation 60000

194 S6.6.2 Haemangioma SOL Liver Hepatectomy + Wedge Resection 75000

195 S6.6.3 Hydatid cyst-Marsupilisation 30000

Gall Bladder

S6.7 Gall Bladder

196 S6.7.1 Cyst excision + Hepatic Jejunostomy 45000

197 S6.7.2 Cholecystectomy 15000

198 S6.7.3 GB+ Calculi CBD Stones or Dilated CBD 25000

199 S6.7.4 Lap.Cholecystectomy 30000

200 S6.7.5 Hepatico Jejunostomy 45000

201 S6.7.6 Choledochoduodenostomy Or Choledocho jejunostomy 35000

S6.8 Spleen

202 S6.8.1 Splenectomy 35000

203 S6.8.2 Splenectomy + Devascularisation + Spleno Renal Shunt 60000

204 S6.8.3 Spleenectomy for Space occupying lesion 35000

S6.9 Pancreas

205 S6.9.1 Lap- Pancreatic Necrosectomy 100000

206 S6.9.2 Lateral PancreaticoJejunostomy(Non- Malignant) 100000

207 S6.9.3 Pancreatic Necrosectomy (open) 100000

208 S6.9.4 Distal Pancreatectomy + Splenectomy 100000

209 S6.9.5 Central Pancreatectomy 100000

S6.9.6 Pseudocyst

210 S6.9.7 Cysto Jejunostomy 40000

211 S6.9.8 Cysto Gastrostomy 40000

S6.10 Hernia

212 S6.10.1 Diaphragmatic Hernia (Gortex Mesh Repair) 40000

S6.11 LIVER SURGERES

S6.11 LIVER

213 S6.11.1 Rt.Hepatectomy 75000

214 S6.11.2 Lt.Hepatectomy 75000

215 S6.11.3 Segmentectomy 50000

S6.12 PANCREATIC SURGERES

S6.12 PANCREAS

216 S6.12.1 Distal Pancreatectomy 100000

217 S6.12.2 Enucleation of Cyst 75000

218 S6.12.3 Whipples - any type 75000

219 S6.12.4 Triple Bypass 25000

220 S6.12.5 Other Bypasses 25000

S7 CARDIAC AND CARDIOTHORACIC SURGERY

33

S7.1 CARDIAC INTERVENTIONS/PROCEDURES

S7.1.1 Coronary Artery Disease

221 S7.1.1.1 Coronary Balloon Angioplasty 60000

222 S7.1.1.2 PTCA Additional Stent 20000

S7.1.2 ASD and VSD

223 S7.1.2.1 ASD Device closure 80000

224 S7.1.2.2 VSD Device closure 80000

S7.1.3 Patent Ductus Arteriousus

225 S7.1.3.1 PDA Stenting 65000

226 S7.1.3.2 Device closure 60000

S7.1.3.3 Coil closure

227 S7.1.3.3.1 Single coil 20000

228 S7.1.3.3.2 Multiple coils 30000

S7.1.4 Balloon procedures

229 S7.1.4.1 Balloon Valvotomy 20000

230 S7.1.4.2 Balloon Atrial septostomy 30000

S7.1.5 Pacemaker Implantation

231 S7.1.5.1 Permanent Pacemaker Implantation 75000

232 S7.1.5.2 Temporary Pacemaker Implantation 10000

S7.1.6 Coarctation of Aorta Repair/Aortoplasty

233 S7.1.6.1 With stent 80000

234 S7.1.6.2 Without stent 30000

S7.1.7 Angioplasty

235 S7.1.7.1 Renal Angioplasty 60000

236 S7.1.7.2 Peripheral Angioplasty 60000

237 S7.1.7.3 Vertebral Angioplasty 75000

238 S7.1.7.4 Additional Stent 40000

S7.2 CARDIOTHORACIC AND VASCULAR SURGERIES

S7.2.1 Surgery for CAD

239 S7.2.1.1 Coronary Bypass Surgery 95000

240 S7.2.1.2 Coronary Bypass Surgery-post Angioplasty 105000

241 S7.2.1.3 CABG with IABP pump 125000

242 S7.2.1.4 CABG with aneurismal repair 110000

S7.2.2 Intracardiac Tumors

243 S7.2.2.1 Surgery for Intracardiac Tumors 75000

S7.2.3 Sinus of Valsalva

244 S7.2.3.1 Ruptured sinus of valsulva Correction 95000

S7.2.4 TAPVC

245 S7.2.4.1 TAPVC Correction 95000

S7.2.5 TOF

S7.2.5.1 Systemic Pulmonary Shunts

246 S7.2.5.1.1 With Graft 20000

247 S7.2.5.1.2 Without Graft 20000

248 S7.2.5.2 Total Correction of Tetralogy of Fallot 95000

S7.2.6 ASD and VSD

249 S7.2.6.1 Intracardiac Repair of ASD 75000

250 S7.2.6.2 Intracardiac Repair of VSD 75000

S7.2.7 Patent Ductus Arteriosus

251 S7.2.7.1 Surgery-PDA 20000

S7.2.8 Ross Procedure Intracardiac Repair of Complex congenital heart diseases

252 S7.2.8.1 With Special Conduits 1,25,000

253 S7.2.8.2 Without Special Conduits 95000

S7.2.9 Valve Repairs

254 S7.2.9.1 With Prosthetic Ring 100000

34

255 S7.2.9.2 Without Prosthetic Ring 85000

256 S7.2.9.3 Open Pulmonary Valvotomy 75000

257 S7.2.9.4 Closed mitral valvotomy 20000

258 S7.2.9.5 Mitral Valvotomy (Open) 80000

S7.2.10 Valve Replacement

259 S7.2.10.1 Mitral Valve Replacement (With Valve) 120000

260 S7.2.10.2 Aortic Valve Replacement (With Valve) 120000

261 S7.2.10.3 Tricuspid Valve Replacement 120000

262 S7.2.10.4 Double Valve Replacement (With Valve) 150000

S7.2,11 Pericardium

263 S7.2.11.1 Pericardiostomy 10000

264 S7.2.11.2 Pericardiectomy 30000

265 S7.2.11.3 Pericardiocentesis 2000

S7.2.12 Coarctation-Arota Repair

266 S7.2.12.1 With Graft 32000

267 S7.2.12.2 Without Graft 25000

S7.2.13 Aorta Repair

268 S7.2.13.1 Aneurysm Resection & Grafting 125000

269 S7.2.13.2 Intrathoracic Aneurysm -Aneurysm not Requiring Bypass (with Graft) 65000

270 S7.2.13.3 Intrathoracic Aneurysm -Requiring Bypass (With Graft) 125000

271 S7.2.13.4 Dissecting Aneurysms 75000

272 S7.2.13.5 Annulus aortic ectasia with valved conduits 150000

S7.2.14 Aorto-Aorto Bypass

273 S7.2.14.1 With Graft 60000

274 S7.2.14.2 Without Graft 45000

S7.2.15 Femoro- Poplitial Bypass

275 S7.2.15.1 With Graft 45000

276 S7.2.15.2 Without Graft 30000

S7.2.16 Femoro-ileal Bypass

277 S7.2.16.1 With Graft 45000

278 S7.2.16.2 Without Graft 25000

S7.2.17 Femoro-femoral Bypass

279 S7.2.17.1 With Graft 45000

280 S7.2.17.2 Without Graft 25000

S7.2.18 TGA

281 S7.2.18.1 Arterial Switch 150000

282 S7.2.18.2 Sennings Procedure 120000

S7.2.19 Embolectomy

283 S7.2.19.1 Carotid Embolectomy 50000

CARDIOTHORASIC SURGERIES AND PROCEDURES AAROGYASRI-I

S7.3 LUNGS

284 S7.3.1 Pneumonectomy 50000

285 S7.3.2 Lobectomy 50000

286 S7.3.3 Decortication 50000

287 S7.3.4 Lung Cyst 50000

288 S7.3.5 SOL mediastinum 50000

S7.3.6 Surgical Correction of Bronchopleural Fistula.

289 S7.3.6.1 Thorocoplasty 50000

290 S7.3.6.2 Myoplasty 50000

291 S7.3.6.3 Transpleural BPF closure 50000

CARDIOTHORACIC SURGERIES AND PROCEDURES AAROGYASRI-II

S7.4 CHEST SURGERY

292 S7.4.1 Diaphragmatic Eventeration 40000

293 S7.4.2 Diaphragmatic Hernia 40000

35

294 S7.4.3 Oesophageal Diverticula /Achalasia Cardia 40000

S7.5 DIAPHRAGMATIC INJURIES

295 S7.5.1 Thoracotomy, Thoraco Abdominal Approach 40000

S7.6 BRONCHIAL INJURIES/FB

296 S7.6.1 Foreign Body Removal With Scope 20000

297 S7.6.2 Repair Surgery For Injuries Due To Fb 40000

S7.8 OESOPHAGEAL INJURY/FB

298 S7.8.1

Gastro Study Followed By Thoracotomy & Repairs For Oesophageal Injury For Corrosive Injuries/Fb 50000

S7.9 VASCULAR INJURY

299 S7.9.1 Surgery Without Graft for Arterial Injuries Venous Injuries 10000

300 S7.9.2 Surgery With Vein Graft 15000

301 S7.9.3 With Prosthetic Graft 40000

302 S7.9.1

Vascular Injury in upper limbs - Axillary, brachial, radial and ulnar - Repair with Vein Graft Up to 40000

303 S7.9.2 Major Vascular Injury - in lower limbs – Repair Up to 60000

304 S7.9.3 Minor Vascular Injury Repair - Tibial vessels in leg Up to 20000

305 S7.9.4 Minor Vascular Injury Repair - vessels in Foot Up to 20001

306 S7.9.5 Neck Vascular Injury - Carotid Vessels Up to 100000

307 S7.9.6 Abdominal Vascular Injuries - Aorta, Illac arteries, IVC, iliac Veins Up to 100000

308 S7.9.7 Thoracic Vascular Injuries Up to 150000

S7.10 CARDIAC INJURES

309 S7.10.1 Surgery Without CPB 40000

310 S7.10.2 Surgery With CPB 75000

S7.11 VASCULAR SURGERIES

311 S7.11.1 Peripheral Embolectomy without graft 25000

312 S7.11.2 Aorto Billiac / Bifemoral bypass with Synthetic Graft 125000

313 S7.11.3 Axillo bifemoral bypass with Synthetic Graft 100000

314 S7.11.4 Femoro Distal Bypass with Vein Graft 60000

315 S7.11.5 Femoro Distal Bypass with Synthetic Graft 80000

316 S7.11.6 Axillo Brachial Bypass using with Synthetic Graft 65000

317 S7.11.7 Brachio - Radial Bypass with Synthetic Graft 50000

318 S7.11.8 Excision of Carotid body Tumor with vascular repair 60000

319 S7.11.9 Carotid artery bypass with Synthetic Graft 100000

320 S7.11.10 Excision of Arterio Venous malformation – Large 75000

321 S7.11.11 Excision of Arterio Venous malformation – Small 40000

322 S7.11.12 Arterial Embolectomy 20000

323 S7.11.13 A V Fistula at wrist 10000

324 S7.11.14 A. V Fistula at Elbow 20000

325 S7.11.15 D V T - IVC Filter 100000

326 S7.11.16 Vascular Tumors 40000

327 S7.11.17 Small Arterial Aneurysms – Repair 15000

36

328 S7.11.18 Medium size arterial aneurysms – Repair 50000

329 S7.11.19 Medium size arterial aneurysms with synthetic graft 75000

S8 PEDIATRIC SURGERIES

S8.1 PAEDIATRIC CONGENITAL MALFORMATIONS

S8.1.1 GI Tract

330 S8.1.1 Oesophageal Atresia 60000

331 S8.1.2 Diaphragmatic Hernia 60000

332 S8.1.3 Intestinal Atresias & Obstructions 50000

333 S8.1.4 Biliary Atresia & Choledochal Cyst 55000

334 S8.1.5 Anorectal Malformations Stage 1 45000

335 S8.1.6 Anorectal Malformations Stage 2 60000

336 S8.1.7 Hirschprungs Disease Stage1 45000

337 S8.1.8 Hirschprungs Disease Stage 2 60000

S8.2 UROGENITAL

338 S8.2.1 Congenital Hydronephrosis 50000

339 S8.2.2 Ureteric Reimplantations 65000

340 S8.2.3.1 Extrophy Bladder Stage 1 65000

341 S8.2.3.2 Extrophy Bladder Stage 2 60000

342 S8.2.4 Posterior Urethral Valves 30000

343 S8.2.5 Hypospadias Single Stage 40000

344 S8.2.6.1 Hypospadias Stage1 35000

345 S8.2.6.2 Hypospadias Stage 2 35000

S8.3 PEDIATRIC TUMORS

346 S8.3.1 Paediatric Tumors 50000

S8.4 PLASTIC REPAIR

347 S8.4.1 Cleft lip 10000

348 S8.4.2 Cleft Palate 15000

349 S8.4.3 Velo-Pharyngeal Incompetence 15000

350 S8.4.4 Syndactyly of Hand for each hand 15000

351 S8.4.5 Microtia/Anotia 30000

352 S8.4.6 TM joint ankylosis 40000

PEDIATRIC SURGERIES

S8.5 Congenital Malformations

353 S8.5.1 Hamartoma Excision 20000

354 S8.5.2 Hemangioma Excision 25000

355 S8.5.3 Lymphangioma Excision 40000

S8.6 HEAD AND NECK

356 S8.6.1 Neuroblastoma 25000

357 S8.6.2 Congenital Dermal Sinus 30000

358 S8.6.3 Cystic Lesions of the Neck 20000

359 S8.6.4 Encephalocele 20000

360 S8.6.5 Sinuses & Fistula of the Neck 20000

S8.7 CHEST

361 S8.7.1 Bronchoscopy foreign body removal 20000

362 S8.7.2 Paediatric Esophageal obstructions-Surgical correction 30000

363 S8.7.3 Paediatric Esophageal Substitutions 60000

364 S8.7.4 Thoracoscopic cysts excision 40000

365 S8.7.5 Thoracoscopic decortications 40000

366 S8.7.6 Thoracic Duplications 40000

367 S8.7.7 Thoracic Wall defects- Correction 50000

S8.8 ABDOMEN

368 S8.8.1 Gastric outlet obstructions 30000

369 S8.8.2 Gastro Esophageal Reflux Correction 30000

370 S8.8.3 Hydatid cysts in Paediatric patient 40000

371 S8.8.4 Intestinal Polyposis Surgical correction 50000

37

372 S8.8.5 Intususception 40000

373 S8.8.6 Paediatric Acute Intestinal Obstruction 40000

374 S8.8.7 Laparoscopic Appendicectomy 30000

375 S8.8.8 Laparoscopic Choleycystectomy 40000

376 S8.8.9 Laparoscopic pull through for Ano Rectal Anomalies 60000

377 S8.8.10 Laparoscopic pull through surgeries for HD 60000

378 S8.8.11 Paediatric Splenectomy (Non Traumatic) 35000

379 S8.8.12 Surgeries on adrenal gland in Children 25000

S8.9 GENITOURINARY SYSTEM

380 S8.9.1 Nephrectomy 40000

381 S8.9.2 Epispadiasis – Correction 40000

382 S8.9.3 Scrotal transposition repair 20000

383 S8.9.4 Undescended Testis 25000

384 S8.9.5 Torsion Testis 25000

385 S8.9.6 Laparoscopic Orchidopexy 25000

386 S8.9.7 Laparoscopic Varicocele ligation 25000

S9 GENITO URINARY SURGERIES

S9.1 Renal Transplantation

387 S9.1.1 A.V. Fistula as Pre-Transplant Procedure 10000

388 S9.1.2 Renal Transplantation surgery 140000

389 S9.1.3

Post Transplant immunosuppressive Treatment from 1st to 6th Month after transplantation 50000

S9.2 Surgery for Renal Calculi

390 S9.2.1 Open Pyelolithotomy 10000

391 S9.2.2 Open Nephrolithotomy 10000

392 S9.2.3 Open Cystolithotomy 10000

393 S9.2.4 Laparoscopic Pyelolithotomy 30000

S9.3 Lithotripsy Procedures

394 S9.3.1 Cystolithotripsy 10000

395 S9.3.2 PCNL 30000

396 S9.3.3 ESWL 20000

397 S9.3.4 URSL 25000

398 S9.3.5 Nephrostomy 2000

399 S9.3.6 DJ stent (One side) 5000

S9.4 Other Corrective Surgeries/Procedures

S9.4.1 Urethroplasty for Stricture Diseases

400 S9.4.1.1 Single stage 50000

S9.4.1.2 Double Stage

401 S9.4.1.2.1 Stage-1 30000

402 S9.4.1.2.2 Stage-2 30000

403 S9.4.2 Reconstruction Procedure 50000

S9.4.3 Hypospadiasis(Adult)

404 S9.4.3.1 Single Stage 40000

S9.4.3.2 Double stage

405 S9.4.3.2.1 Stage-1 35000

406 S9.4.3.2.2 Stage-2 35000

407 S9.4.4 TURBT 30000

GENITOURINARY SURGERIES AAROGYASRI-II

S9.5 Renal Transplantation

408 S9.5.1

Post Transplant immunosuppressive Treatment from 7th to 12 th Month after transplantation 50000

S9.6 RENAL

409 S9.6.1 Nephrostomy 10000

410 S9.6.2 Nephrectomy Pyonephrosis/XGP 40000

38

411 S9.6.3 Simple Nephrectomy 40000

412 S9.6.4 Lap. Nephrectomy Simple 30000

413 S9.6.5 Lap. Nephrectomy Radical 40000

414 S9.6.6 Lap. Partial Nephrectomy 35000

415 S9.6.7

Bilateral

25000 Nephroureterectomy

416 S9.6.8 Renal Cyst Excision 15000

S9.7 RENAL STONE SURGERY/THERAPIES

417 S9.7.1 Endoscope Removal of stone in Bladder 10000

418 S9.2.5 Anatrophic Peylolithotomy for Staghorn Caliculus 50000

S9.8 CORRECTIVE SURGERIES

419 S9.8.1 Anderson Hynes Pyeloplasty 40000

420 S9.8.2 Vasico Vaginal Fistula 40000

421 S9.8.3 Epispadiasis – Correction 40000

422 S9.8.4 Closure of Urethral Fistula 25000

423 S9.8.5 Optical Urethrotomy 20000

424 S9.8.6 Perineal Urethrostomy 20000

425 S9.8.7 Ureteric Reimplantation 25000

426 S9.8.8 Ileal Conduit formation 20000

427 S9.8.9 Ureterocele 15000

S9.9 BLADDER and PROSTATE

428 S9.9.1 Transurethral resection of prostate (TURP) 30000

429 S9.9.2 TURP Cyst lithotripsy 30000

430 S9.9.3 Open prostatectomy 30000

431 S9.9.4 Caecocystoplasty 30000

432 S9.9.5 Total cystectomy 35000

433 S9.9.6 Diverticulectomy 10000

434 S9.9.7

Incontinence Urine

20000 (Female)

435 S9.9.8

Incontinence Urine

20000 (male)

S9.10 TESTIS AND PENIS

436 S9.10.1 Orchidopexy Bilateral 15000

437 S9.10.2 Torsion testis 12000

438 S9.10.3 Chordee correction 15000

439 S9.10.4

Partial amputation of

15000 Penis(Non-Malignant)

440 S9.10.5

Total amputation of

25000 Penis(Non-Malignant)

S10 NEUROSURGERY

S10.1 BRAIN

441 S10.1.1 Craniotomy and Evacuation of Haematoma –Subdural 60000

442 S10.1.2 Craniotomy and Evacuation of Haematoma –Extradural 60000

443 S10.1.3 Evacuation of Brain Abscess-burr hole 25000

444 S10.1.4 Excision of Lobe (Frontal,Temporal,Cerebellum etc.) 40000

S10.1.5 Excision of Brain Tumor Supratentorial

445 S10.1.5.1 Parasagital 50000

446 S10.1.5.2 Basal 60000

447 S10.1.5.3 Brain Stem 70000

448 S10.1.5.4 C P Angle 70000

449 S10.1.5.5 Others 40000

450 S10.1.11 Excision of Brain Tumors –Subtentorial 45000

451 S10.1.12 Ventriculoatrial /Ventriculoperitoneal Shunt 20000

39

452 S10.1.13 Twist Drill Craniostomy 15000

453 S10.1.14 Subdural Tapping 15000

454 S10.1.15 Ventricular Tapping 15000

455 S10.1.16 Abscess Tapping 20000

456 S10.1.17 Vascular Malformations 40000

457 S10.1.18 Peritoneal Shunt 20000

458 S10.1.19 Atrial Shunt 20000

459 S10.1.20 Meningo Encephalocele 25000

460 S10.1.21 Meningomyelocele 25000

461 S10.1.22 C.S.F. Rhinorrhoea 20000

462 S10.1.23 Cranioplasty 30000

463 S10.1.24 Meningocele Excision 25000

464 S10.1.25 Ventriculo-Atrial Shunt 20000

465 S10.1.26 Excision of Brain Abcess 60000

466 S10.1.27 Aneurysm Clipping 100000

467 S10.1.28 External Ventricular Drainage (EVD) 40000

S10.2 SPINAL SURGERIES

468 S10.2.1 Surgery of Cord Tumours 25000

469 S10.2.2 Excision of Cervical Inter-Vertebral Discs 25000

470 S10.2.3 Posterior Cervical Discectomy 15000

471 S10.2.4 Anterior Cervical Discectomy 15000

472 S10.2.5 Anterior Cervical Spine Surgery with fusion 45000

473 S10.2.6 Anteriolateral Decompression 30000

474 S10.2.7 Laminectomy 25000

475 S10.2.8 Discectomy 25000

476 S10.2.9 Spinal Fusion Procedure 50000

477 S10.2.10 Spinal Intra Medullary Tumours 50000

478 S10.2.11 Spina Bifida Surgery Major 20000

479 S10.2.12 Spina Bifida Surgery Minor 15000

S10.3 OTHER SURGERIES/PROCEDURES

480 S10.3.1 Stereotactic Procedures 20000

481 S10.3.2 Trans Sphenoidal Surgery 20000

482 S10.3.3 Trans Oral Surgery 25000

483 S10.3.4 Combined Trans-oral Surgery & CV Junction Fusion 30000

484 S10.3.5 C.V. Junction Fusion 20000

NEUROSURGERY

S10.4 BRAIN

485 S10.4.1 Endoscopy procedures 65,000

486 S10.4.1.1 Endoscopic Third Ventriclostomy(ETV) 30,000

487 S10.4.2 Intra-Cerebral Hematoma evacuation 60,000

488 S10.4.3 Decompressive Craniectomy 50,000

S10.5 SPINE

489 S10.5.1 Anterior discectomy & bone grafting 40,000

490 S10.5.2 Discectomy with Implants 65,000

491 S10.5.3 Corpectomy for Spinal Fixation 70,000

492 S10.5.4 Spinal Fixation Rods and Plates, Artificial discs 85,000

493 S10.5.5 Syringomyelia 65,000

S10.6 SOFT TISSUE and VASCULAR SURGERIES

494 S10.6.1 Repair of Brachial plexus injury 60,000

495 S10.6.2 Cervical Sympathectomy 50,000

496 S10.6.3 Lumbar sympathectomy 50,000

497 S10.6.4 Decompression/Excision of Optic nerve lesions 65,000

498 S10.6.5 Peripheral nerve injury repair 50,000

499 S10.6.6 Proptosis 60,000

40

500 S10.6.7 Decompression/Excision of Optic Nerve Lesions* 65000

S10.7 EPILEPSY Surgery

501 S10.7.1 Temporal Lobectomy 90 000

502 S10.7.2 Lesionectomy type 1 1 50 000

503 S10.7.3 Lesionectomy type 2 160 000

504 S10.7.4 Temporal lobectomy plus Depth Electrodes 140 000

S10.8 MANAGEMENT OF TRIGEMINAL NEURALGIA

505 S10.8.1 Radiofrequency ablation for Trigeminal Neuralgia 30000

506 S10.8.2 Microvascular decompression for Trigeminal Neuralgia 60000

S10.9 MANAGEMENT OF ANEYRISMS

507 S10.9.1 Embolization of Aneurysm 50000

508 S10.9.2 Cost of each coil 30000

S11 SURGICAL ONCOLOGY

CANCER – Surgeries

S11.1 Head & Neck

509 S11.1.1 Composite Resection & Reconstruction 60000

510 S11.1.2 Neck Dissection - any type 25000

511 S11.1.3 Hemiglossectomy 15000

512 S11.1.4 Maxillectomy - any type 25000

513 S11.1.5 Thyroidectomy - any type 20000

514 S11.1.6 Parotidectomy - any type 20000

515 S11.1.7 Laryngectomy - any type 40000

516 S11.1.8 Laryngopharyngo Oesophagectomy 75000

517 S11.1.9 Hemimandibulectomy 25000

518 S11.1.10 Wide excision 25000

S11.2 Gastrointestinal Tract

519 S11.2.1 Oesophagectomy - any type 60000

520 S11.2.2 Gastrectomy - any type 40000

521 S11.2.3 Colectomy - any type 40000

522 S11.2.4 Anterior Resection 50000

523 S11.2.5 Abdominoperinial Resection 40000

524 S11.2.6 Whipples - any type 75000

525 S11.2.7 Triple Bypass 25000

526 S11.2.8 Other Bypasses-Pancreas 25000

S11.3 Genito Urinary System

527 S11.3.1 Radical Nephrectomy 40000

528 S11.3.2 Radical Cystectomy 60000

529 S11.3.3 Other Cystectomies 40000

530 S11.3.4 Total Penectomy 25000

531 S11.3.5 Partial Penectomy 15000

532 S11.3.6 Inguinal Block Dissection - one side 15000

533 S11.3.7 Radical Prostatectomy 60000

534 S11.3.8 High Orchidectomy 15000

535 S11.3.9 Bilateral Orchidectomy 10000

536 S11.3.10 Emasculation 30000

S11.4 Gynaecological Oncology

537 S11.4.1 Hysterectomy 25000

538 S11.4.2 Radical Hysterectomy 30000

539 S11.4.3 Surgery for Ca Ovary - early stage 25000

540 S11.4.4 Surgery for Ca Ovary - advance stage 40000

541 S11.4.5 Vulvectomy 15000

542 S11.4.6 Salpingo – oophorectomy 25000

S11.5 Tumors of the Female Breast

41

543 S11.5.1 Mastectomy - any type 25000

544 S11.5.2 Axillary Dissection 15000


546 S11.5.4 Lumpectomy 3000

547 S11.5.5 Breast reconstruction 25000

548 S11.5.6 Chest wall resection 20000

S11.6 Skin Tumors


550 S11.6.2 Wide excision + Reconstruction 20000

551 S11.6.3 Amputation 20000

S11.7 Soft Tissue and Bone Tumors


553 S11.7.2 Wide excision + Reconstruction 25000

554 S11.7.3 Amputation 20000

S11.8 Lung Cancer

555 S11.8.1 Pneumonectomy 50000

556 S11.8.2 Lobectomy 50000

557 S11.8.3 Decortication 50000

S11.8.4 Surgical Correction of Bronchopleural Fistula.

558 S11.8.4.1 Thoracoplasty 50000

559 S11.8.4.2 Myoplasty 50000

560 S11.8.4.3 Transpleural BPF closure 50000

SURGICAL ONCOLOGY AAROGYASRI-II

S11.9 Ca.Oral cavity

561 S11.9.1 MarginalMandibulectomy 25,000

562 S11.9.2 Segmental Mandibulectomy 25,000

563 S11.9.3 Total glossectomy + Reconstruction 40,000

564 S11.9.4 Full thickness Buccal mucosal resection & Reconstruction 50,000

S11.10 Ca.Eye/ Maxilla /Para Nasal Sinus

565 S11.10.1 Orbital exenteration 25,000

566 S11.10.2 Maxillectomy + Orbital exenteration 35,000

567 S11.10.3 Maxillectomy + Infratemporal Fossa clearance 40,000

568 S11.10.4 Cranio Facial Resection 70,000

S11.11 Ca. Nasopharynx

569 S11.11.1 Resection of Nasopharyngeal Tumor 50,000

S11.12 Ca.Soft Palate

570 S11.12.1 Palatectomy Any type 30,000

S11.13 Ca. Ear

571 S11.13.1 Sleeve Resection 25,000

572 S11.13.2 Lateral Temporal bone resection 30,000

573 S11.13.3 Subtotal Temporal bone resection 50,000

574 S11.13.4 Total Temporal bone resection 60,000

S11.14 Ca. Salivary Gland

575 S11.14.1 Submandibular Gland Excision 20,000

S11.15 Ca. Thyroid

576 S11.15.1 Tracheal Resection 52,000

S11.16 Ca. Trachea

577 S11.16.1 Sternotomy + Superior Mediastinal Dissection 45,000

578 S11.16.2 Tracheal Resection 40,000

S11.17 Ca. Parathyroid

579 S11.17.1 Parathyroidectomy 30,000

S11.18 Ca. Gastro Intestinal Tract

580 S11.18.1 Small bowel resection 40,000

581 S11.18.2 Closure of Ileostomy 20,000

42

582 S11.18.3 Closure of Colostomy 20,000

S11.19 Ca.Rectum

583 S11.19.1 Abdomino Perineal Resection (APR) + Sacrectomy 50,000

584 S11.19.2 Posterior Exenteration 50,000

585 S11.19.3 Total Exenteration 75,000

S11.20 Ca. Gall Bladder

586 S11.20.1 Radical Cholecystectomy 60,000

S11.21 Spleen

587 S11.21.1 Splenectomy 35,000

S11.22 Retroperitoneal Tumor

588 S11.22.1 Resection of Retroperitoneal Tumors 45,000

S11.23 Abdominal wall tumor

589 S11.23.1 Abdominal wall tumor Resection 35,000

590 S11.23.2 Resection with reconstruction 45,000

S11.24 Gynaec Cancers

591 S11.24.1 Bilateral pelvic lymph Node Dissection(BPLND) 25,000

592 S11.24.2 Radical Trachelectomy 40,000

593 S11.24.3 Radical vaginectomy 40,000

594 S11.24.4 Radical vaginectomy + Reconstruction 45,000

S11.25 Ca. Cervix

595 S11.25.1

Radical Hysterectomy +Bilateral Pelvic Lymph Node Dissection (BPLND) + Bilateral Salpingo Ophorectomy (BSO) / Ovarian transposition 45,000

596 S11.25.2 Anterior Exenteration 60,000

597 S11.25.3 Posterior Exenteration 50,000

598 S11.25.4 Total Pelvic Exenteration 75,000

599 S11.25.5 Supra Levator Exenteration 70,000

S11.26 Ca. Endometrium

600 S11.26.1

Total Abdominal Hysterectomy(TAH)+Bilateral Salpingo ophorectomy (BSO)+Bilateral pelvic lymph Node Dissection (BPLND)+ Omentectomy 35,000

S11.27 Soft tissue /Bone tumors - Chest wall

601 S11.27.1 Chest wall resection 20,000

602 S11.27.2 Chest wall resection + Reconstruction 30,000

S11.28 Bone / Soft tissue tumors

S11.28.1 Limb salvage surgery

603 S11.28.1.1 -Without prosthesis 40,000

604 S11.28.1.2 -With Custom made Prosthesis 50,000

605 S11.28.1.3 -With Modular Prosthesis 75,000

606 S11.28.2 Forequarter amputation 40,000

607 S11.28.3 Hemipelvectomy 55,000

608 S11.28.4 Internal hemipelvectomy 65,000

609 S11.28.5 Curettage & bone cement 30,000

610 S11.28.6 Bone resection 30,000

611 S11.28.7 Shoulder girdle resection 40,000

612 S11.28.8 Sacral resection 60,000

S11.29 Genito urinary Cancer

613 S11.29.1 Partial Nephrectomy 55,000

614 S11.29.2 Nephroureterectomy for Transitional Cell Carcinima of renal pelvis 50,000

S11.30 Testes cancer

615 S11.30.1 Retro Peritoneal Lymph Node Dissection(RPLND) (for Residual Disease) 60,000

616 S11.30.2 Adrenalectomy 45,000

43

617 S11.30.3 Urinary diversion 40,000

618 S11.30.4 Retro Peritoneal Lymph Node Dissection RPLND as part of staging 20,000

S11.31 Ca. Urinary Bladder

619 S11.31.1 Anterior Exenteration 60,000

620 S11.31.2 Total Exenteration 75,000

621 S11.31.3 Bilateral pelvic lymph Node Dissection(BPLND) 20,000

S11.32 Thoracic and Mediastinum

622 S11.32.1 Mediastinal tumor resection 50,000

S11.33 Lung

623 S11.33.1 Lung metastatectomy – solitary 50,000

624 S11.33.2 Lung metastatectomy – Multiple 60,000

625 S11.33.3 Sleeve resection of Lung cancer. 90,000

S11.34 Esophagus

626 S11.34.1 Oesophagectomy with Two field Lymphadenectomy 90,000

627 S11.34.2 Oesophagectomy with Three field Lymphadenectomy 1,00,000

S11.35 Palliative Surgeries

628 S11.35.1 Tracheostomy 5,000

629 S11.35.2 Gastrostomy 20,000

630 S11.35.3 Jejunostomy 20,000

631 S11.35.4 Ileostomy 20,000

632 S11.35.5 Colostomy 20,000

633 S11.35.6 Suprapubic Cystostomy 10,000

634 S11.35.7 Intercostal Drainage(ICD) 3,000

635 S11.35.8 Gastro Jejunostomy 35,000

636 S11.35.9 Ileotransverse Colostomy 50,000

637 S11.35.10 Substernal bypass 35,000

S11.36 Reconstruction

638 S11.36.1 Myocutaneous / cutaneous flap 25,000

639 S11.36.2 Micro vascular reconstruction 45,000

S12 MEDICAL ONCOLOGY AAROGYASRI-I

CANCER - Chemotherapy*

S12.1 Breast Cancer

640 S12.1.1 Adriamycin/Cyclophosphamide (AC) 3000

641 S12.1.2 5- Fluorouracil A-C (FAC) 3100

642 S12.1.3 AC (AC then T) 3000

643 S12.1.4 Paclitaxel 9500

644 S12.1.5 Cyclophosphamide/Methotrexate/5Fluorouracil (CMF) 1500

645 S12.1.6 Tamoxifen tabs 85/month

646 S12.1.7 Aromatase Inhibitors 835/month

S12.2 Cervical Cancer

647 S12.2.1 Weekly Cisplatin 2000

S12.3 Vulval Cancer

648 S12.3.1 Cisplatin/5-FU 5000

S12.4 Vaginal Cancer

649 S12.4.1 Cisplatin/5-FU 5000

S12.5 Ovarian Cancer

650 S12.5.1 Carboplatin/Paclitaxel 10500

S12.6 Ovary- Germ Cell Tumor

651 S12.6.1 Bleomycin-Etoposide-Cisplatin (BEP) 8000

S12.7 Gestational Trophoblast Ds.

S12.7.1 Low risk

652 S12.7.1.1 Weekly Methotrexate 600

653 S12.7.1.2 Actinomycin 3000

44

S12.7.2 High risk

654 S12.7.2.1 Etoposide-Methotrexate-Actinomycin / Cyclophosphamide -Vincristine (EMA-CO) 6000

S12.8 Testicular Cancer

655 S12.8.1 Bleomycin-Etoposide-Cisplatin (BEP) 8000

S12.9 Prostate Cancer

656 S12.9.1 Hormonal therapy 3000/month

S12.10 Bladder Cancer

657 S12.10.1 Weekly Cisplatin 2000

658 S12.10.2 Methotrexate Vinblastine Adriamycin Cyclophosphamide (MVAC) 5000

S12.11 Lung Cancer

Non-small cell lung cancer

659 S12.11.1 Cisplatin/Etoposide (IIIB) 7000

S12.12 Oesophageal Cancer

660 S12.12.1 Cisplatin- 5FU 5000

S12.13 Gastric Cancer

661 S12.13.1 5-FU -Leucovorin (McDonald Regimen) 5000

S12.14 Colorectal Cancer

662 S12.14.1 Monthly 5-FU 4000

663 S12.14.2 5-Fluorouracil-Oxaliplatin -Leucovorin (FOLFOX) (Stage III only) 10000

S12.15 Osteosarcoma/ Bone Tumors

664 S12.15.1 Cisplatin/Adriamycin 20000

S12.16 Lymphoma

S12.16.1 i) Hodgkin Disease

665 S12.16.1.1 Adriamycin - Bleomycin - Vinblastine Dacarbazine (ABVD) 4000

S12.16.2 ii) NHL

666 S12.16.2.1 Cyclophosphamide - Adriamycin Vincristine - Prednisone (CHOP) 3500

S12.17 Multiple Myeloma

667 S12.17.1 Vincristine, Adriamycin,Dexamethasone(VAD) 4000

668 S12.17.2 Thalidomide+Dexamethasone(Oral) 3000

669 S12.17.3 Melphalan -Prednisone (oral) 1500

S12.18 Wilm's Tumor

670 S12.18.1 SIOP/NWTS regimen(Stages I - III) 7000/month

S12.19 Hepatoblastoma- operable

671 S12.19.1 Cisplatin – Adriamycin 15000

S12.20 Childhood B Cell Lymphomas

672 S12.20.1 Variable Regimen Up to 12000

S12.21 Neuroblastoma ( Stages I-III )

673 S12.21.1 Variable Regimen Up to 10000

S12.22 Retinoblastoma

674 S12.22.1 Carbo/Etoposide/Vincristine 4000

S12.23 Histiocytosis

675 S12.23.1 Variable Regimen Up to

8000/month

S12.24 Rhabdomyosarcoma

676 S12.24.1 Vincristine-Actinomycin-Cyclophosphamide(VactC) based chemo 9000/month

S12.25 Ewings sarcoma

677 S12.25.1 Variable Regimen Up to 9000/

month

S12.26 Acute Myeloid Leukemia

678 S12.26.1 Induction Phase Up to 60000

679 S12.26.2 Consolidation Phase Up to 40000

S12.27 Acute Lymphoblastic Leukemia

45

S12.27.1 Induction

680 S12.27.1.1 1st and 2nd months Up to 50000

681 S12.27.1.2 3rd, 4th, 5th Up to 20000

682 S12.27.1.3 Maintenance 3000 per month

S12.28 For unlisted regimen

683 S12.28.1 Palliative Chemotherapy Upto 5000/cycle

S12.29 For Terminally ill Cancer Patient

684 S12.29.1 Palliative and Supportive Therapy 3000/month

MEDICAL ONCOLOGY AAROGYASRI-II

S12.30 Colo Rectal Cancer Stage 2 and 3

685 S12.30.1 XELOX along with Adjuvant chemotherapy of AS-I 4000

S12.31 MULTIPLE MYELOMA

686 S12.31.1 Zoledronic acid along with Adjuvant Chemotherapy of AS-I 3000

S12.32 FEBRILE NEUTROPENIA

FN - High risk 1

687 S12.32.1

1ST Line iv antibiotics And other supportive therapy ( third generation cephalosporin, aminoglycoside etc.,) 9000

FN - High risk 2

688 S12.32.2

2nd line iv antibiotics and other supportive therapy(Carbapenems, Fourth generation cephalosporins, Piperacillin, anti-fungal - azoles etc.,) 30000

S13 RADIATION ONCOLOGY AAROGYASRI-I

RADIOTHERAPY

S13.1 Cobalt 60 External Beam Radiotherapy

689 S13.1.1 Radical Treatment 20,000

690 S13.1.2 Palliative Treatment 10,000

691 S13.1.3 Adjuvant Treatment 15,000

S13.2 External Beam Radiotherapy (on linear accelerator)

692 S13.2.1 Radical Treatment with Photons 50,000

693 S13.2.2 Palliative Treatment with Photons 20,000

694 S13.2.3 Adjuvant Treatment with Photons/Electrons 35,000

S13.3 Brachytherapy

S13.3.1 A) Intracavitary

695 S13.3.1.1 i. LDR per application 4,500

696 S13.3.1.2 ii. HDR per application 2,500

S13.3.2 B) Interstitial

697 S13.3.2.1 i. LDR per application 15,000

698 S13.3.2.2 ii. HDR - one application and multiple dose fractions 25,000

RADIATION ONCOLOGY AAROGYASRI-II

S13.4 SPECIALIZED RADIATION THERAPY

S13.4.1 IMRT (Intensity modulated radiotherapy)

699 S13.4.1.1 Upto 40 fractions in 8 weeks 100000

S13.4.2 3DCRT(3-D conformational radiotherapy)


S13.4.3 SRS/SRT


S14 PLASTIC SURGERY

S14.1 PLASTIC REPAIR

702 S14.1.1 Cleft lip 10000

703 S14.1.2 Cleft Palate 15000

704 S14.1.3 Velo-Pharyngial Incompetence 15000

705 S14.1.4 Syndactyly of Hand for each hand 15000

46

706 S14.1.5 Microtia/Anotia 30000

707 S14.1.6 TM joint ankylosis 40000

S14.2 BURNS

S14.2.1 30% - 50% Burns

708 S14.2.1.1 upto-40% with Scalds( Conservative) 35,000

709 S14.2.1.2 upto-40% Mixed Burns(with Surgeries) 50,000

710 S14.2.1.3 upto-50% with Scalds (Conservative) 60,000

711 S14.2.1.4 upto-50% Mixed Burns( with Surgeries) 70,000

S14.2.2 Above 50% Burns

712 S14.2.2.1 upto-60% with Scalds (Conservative) 80000

713 S14.2.2.2 Up to-60% Mixed Burns (with Surgeries) 1,00,000

714 S14.2.2.3 Above 60% Mixed Burns (with Surgeries) 1,20,000

S14.3

Post Burn Contracture surgeries for Functional Improvement(Package including splints, pressure garments and physiotherapy)

715 S14.3.1 Mild 20000

716 S14.3.2 Moderate 30000

717 S14.3.3 Severe 40000

PLASTIC SURGERY

718 S14.4 Corrective Surgery for Congenital deformity of hand (per hand) 15,000

719 S14.5 Corrective Surgery for Craniosynostosis 50,000

720 S14.6 Cup and Bat ears 20,000

721 S14.7 Flapcover for Electrical burns with vitals exposed 50,000

722 S14.8 Reduction surgery for Filarial lymphoedema 20,000

723 S14.9 Hemifacial atrophy 30,000

724 S14.10 Hemifacial Microsmia 50,000

725 S14.11 Leprosy reconstructive surgeroy 20,000

726 S14.12 Nerve and tendon repair + Vascular repair 30,000

727 S14.13 Ptosis 25,000

728 S14.14 Tumour of mandible and maxilla 40,000

729 S14.15 Vaginal atresia 25,000

730 S14.16 Vascular malformations 25,000

S15 POLY TRAUMA

POLY TRAUMA & ACCIDENT SURGERIES

S15.1 Orthopedic Trauma

731 S15.1.1 Open Reduction and Internal Fixation of Long Bone Fractures 22000

732 S15.1.2 Amputation Surgery 5000

733 S15.1.3 Soft Tissue Injury 5000

S15.2 Neuro-Surgical Trauma

S15.2.1 Conservative

734 S15.2.1.1 Stay in General [email protected]/day 6000

735 S15.2.1.2 Stay in Neuro [email protected]/day 48000

736 S15.2.2 Surgical Treatment (Up to) 150000

S15.3 Chest Injuries



738 S15.3.1.2 Stay in Respiratory [email protected]/day 20000

739 S15.3.2 Surgical treatment 50000

S15.4 Abdominal Injuries



741 S15.4.1.2 Stay in Surgical [email protected]/day 7000

742 S15.4.2 Surgical treatment 75000

mailto:[email protected]/day






47

S15.5 Emergency Room Procedures

743 S15.5.1 Tracheostomy 3000

744 S15.5.2 Thoracostomy 3000

Orthopedic &Facial boneTrauma

S15.6 Wound Management for Compound Fractures

745 S15.6.1 Grade-I& II 10000

746 S15.6.2 Grade-III 20000

747 S15.6.3 Flap cover Surgery for wound in compound fracture 20000

S15.7

Other Small bone fractures/K-wiring (To be covered along with other injuries only and not as exclusive procedure)

748 S15.7.1

Surgery for Patella fracture (To be covered along with other injuries only and not as exclusive procedure) 5000

749 S15.7.2

Small bone fractures/K-wiring (To be covered along with other injuries only and not as exclusive procedure) 5000

S15.8 Facial Injuries

750 S15.8.1 Facial bone fractures (Facio-Maxillary Injuries) 15000

S15.9 Pelvic Bone fracture

751 S15.9.1 Surgical Correction of Pelvic bone fractures. 20000

S16 COCHLEAR IMPLANT SURGERY

Cochlear Implant Surgery For Children Below 6 Years

752 S16.1 Cochlear Implant Surgery 520000

S16.2 Auditory-Verbal Therapy

753 S16.2.1 Initial Mapping/Switch on 50000

754 S16.2.2

Post Switch on Mapping/Initiation of AVP and training of Child and Mother - First Installment 20000

755 S16.2.3

Post Switch on Mapping/Initiation of AVP and training of Child and Mother - Second Installment 20000

756 S16.2.4

Post Switch on Mapping/Initiation of AVP and training of Child and Mother - Third Installment 20000

757 S16.2.5

Post Switch on Mapping/Initiation of AVP and training of Child and Mother - Fourth Installment 20000

S16.3 HEARING IMPAIRED

758 S.16.3.1 Behind Ear Analogue Hearing Aid 10000

S17 PROSTHESES

Prostheses (Artificial Limbs)

S17.1 LOWER LIMB

S17.1.1 Symes Prostheses

759 S17.1.1.1 HDP/PP 1000

760 S17.1.1.2 Fibre 1200

761 S17.1.1.3 Modular 1500

S17.1.2 Below Knee(BK/PTB) Prostheses

762 S17.1.2.1 HDP/PP 1200

763 S17.1.2.2 Fibre 1500

764 S17.1.2.3 Modular 3000

S17.1.3 Through Knee Prostheses

765 S17.1.3.1 HDP/PP 1500

766 S17.1.3.2 Fibre 1800

767 S17.1.3.3 Modular 3500

48

S17.1.4 Above Knee(AK) Prostheses

768 S17.1.4.1 HDP/PP 1500

769 S17.1.4.2 Fibre 1800

770 S17.1.4.3 Modular 3500

S17.1.5 Hip Disarticulation Prostheses

771 S17.1.5.1 HDP/PP 2500

772 S17.1.5.2 Fibre 3000

773 S17.1.5.3 Modular 6000

774 S17.1.5.4 Partial foot prostheses 500

S17.2 UPPERLIMB

S17.2.1 Below Elbow Prostheses

775 S17.2.1.1 HDP/PP 1500

776 S17.2.1.2 Fibre 1800

777 S17.2.1.3 Modular 3500

S17.2.2 Above Elbow Prostheses

778 S17.2.2.1 HDP/PP 1500

779 S17.2.2.2 Fibre 2000

780 S17.2.2.3 Modular 4000

S17.2.3 Whole Upperlimb prostheses

781 S17.2.3.1 HDP/PP 1000

782 S17.2.3.2 Fibre 1200

783 S17.2.3.3 Modular 1500

MEDICAL PACKAGES

S.No. Code Disease Package

M1 CRITICAL CARE

1 M1.1 Acute severe asthma 45,000

with Acute respiratory

Failure

2 M1.2 COPD Respiratory Failure (infective exacerbation) 70 000

3 M1.3 Acute Bronchitis and Pneumonia with Respiratory failure 50000

4 M1.4 ARDS 80000

5 M1.5 ARDS with Multi Organ failure 100000

6 M1.6 ARDS plus DIC (Blood & Blood products) 120000

7 M1.7 Poison ingestion requiring 30,000

ventilatory assistance

8 M1.8 Septic Shock(ICU Management) 50000

M2 GENERAL MEDICINE

9 M2.1 Thrombocytopenia with bleeding diathesis 50,000

10 M2.2 Hemophilia 50,000

11 M2.3 Other Coagulation disorders 50,000

12 M2.3 Chelation Therapy for Thalassemia Major 20000

13 M2.4 Cerebral Malaria 20000

14 M2.5 TB meningitis 30000

15 M2.6 Snake bite requiring ventilator support 50000

16 M2.7 Scorpion Sting requiring ventilator support 25000

17 M2.8 Metabolic Coma requiring Ventilatory Support 30000

M3 INFECTIOUS DISEASES

18 M3.1 Tetanus severe 20000

19 M3.2 Diphtheria Complicated 25000

20 M3.3 Cryptococcal Meningitis 20,000

M4 PEDIATRICS

M4.1 NEONATAL INTENSIVE CARE

21 M4.1.1 Term baby with culture positive sepsis- Non ventilated Hyperbilirubinemia 25000

49

22 M4.1.2

33 to 34 weeks preterm baby Severe Hyaline membrane disease Clinical sepsis Bubble CPAP Hyperbilirubinemia 40000

23 M4.1.3

33 to 34 weeks preterm baby Severe Hyaline membrane disease Clinical sepsis Mechanical ventilation Hyperbilirubinemia 60000

24 M4.1.4

35 to 36 weeks Preterm Mild Hyaline membrane disease Culture positive sepsis Nonventilated Hyperbilirubinemia 35000

25 M4.1.5

33 to 34 weeks preterm Mild Hyaline membrane disease Culture positive sepsis - Nonventilated Hyperbilirubinemia 45000

26 M4.1.6

33 to 34 weeks preterm Severe Hyaline membrane disease Culture positive sepsis Mechanical ventilation/ Bubble CPAP Hyperbilirubinemia 60000

27 M4.1.7

30 to 32 weeks preterm Severe Hyaline membrane disease Clinical/ Culture positive sepsis Mechanical ventilation Hyperbilirubinemia 90000

28 M4.1.8

<30 weeks preterm Severe Hyaline membrane disease Clinical/ Culture positive sepsis Mechanical ventilation Hyperbilirubinemia 90000

29 M4.1.9

33 to 34 weeks preterm Severe Hyaline membrane disease Clinical/Culture positive sepsis Patent ductus arteriosus- Medical management Mechanical ventilation Hyperbilirubinemia 70000

30 M4.1.10

30 to 32 weeks preterm Severe Hyaline membrane disease Clinical/Culture positive sepsis Patent ductus arteriosus - Medical management Mechanical ventilation Hyperbilirubinemia 90000

31 M4.1.11

<30 weeks preterm Severe Hyaline membrane disease Clinical/Culture positive sepsis Patent ductus arteriosus - Medical management Mechanical ventilation Hyperbilirubinemia 90000

32 M4.1.12

Term baby with persistent pulmonary hypertension Ventilation-HFO Hyperbilirubinemia Clinical sepsis 80000

33 M4.1.13

Term baby with severe perinatal asphyxia - Non ventilated Clinical sepsis Hyperbilirubinemia 25000

34 M4.1.14 Term baby with severe perinatal asphyxia - Ventilated Clinical sepsis Hyperbilirubinemia 40000

35 M4.1.15 Term baby Severe hyperbilirubinemia Clinical sepsis 25000

36 M4.1.16 Term baby with seizures ventilated 25000

37 M4.1.17 Necrotising enterocolitis, Clinical sepsis Non ventilated Hyperbilirubinemia 25000

38 M4.1.18

Term baby, fulminant culture positive sepsis, septic shock, Ventilated, Hyperbilirubinemia Renal failure 40000

M4.2 PEDIATRIC INTENSIVE CARE

M4.2.1 RESPIRATORY

39 M4.2.1.1 Severe Bronchiolitis 15000

(Non Ventilated)

40 M4.2.1.2 Severe Bronchiolitis 20000

( Ventilated)

41 M4.2.1.3 Severe Bronchopneumonia 15000

(non Ventilated)

50

42 M4.2.1.4 Severe Bronchopneumonia 30000

( Ventilated)

43 M4.2.1.5 Acute Severe Asthma 35000

(Ventilated)

44 M4.2.1.6 Severe Aspiration Pneumonia 20000

(Non Ventilated)

45 M4.2.1.7 Severe Aspiration Pneumonia 25000

( Ventilated)

46 M4.2.1.8 ARDS with Multi-organ failure 100000

47 M4.2.1.9 ARDS plus DIC (Blood & Blood products) 120000

M4.2.2 CARDIOVASCULAR

48 M4.2.2.1 Severe Myocarditis 40000

49 M4.2.2.2 Congenital heart disease with infection 30000

(non Ventilated)

50 M4.2.2.3 Congenital heart disease with infection and cardiogenic shock 50000

(Ventilated)

51 M4.2.2.4 Cardiogenic shock 50000

52 M4.2.2.5 Infective Endocarditis 50000

M4.2.3 Central Nervous System

53 M4.2.3.1 Meningo- encephalitis 40000

(Non Ventilated)

54 M4.2.3.2 Meningo- encephalitis 60000

( Ventilated)

55 M4.2.3.3 Status Epilepticus 50000

56 M4.2.3.4 Febrile Seizures 25000

(atypical- mechanical ventilated)

57 M4.2.3.5 Intra cranial bleed 40000

M4.2.4 Gastro intestinal system

58 M4.2.4.1 Acute Gastro intestinal bleed 30000

59 M4.2.4.2 Acute Pancreatitis 50000

60 M4.2.4.3 Acute hepatitis with hepatic encephalopathy 50000

M4.2.5 Renal

61 M4.2.5.1 Acute renal Failure 40000

M4.2.6 Endocrine

62 M4.2.6.1 Diabetes Ketoacidosis 30000

M4.2.7 Infection

63 M4.2.7.1 Septic shock 50000

M4.2.8 Toxicology

64 M4.2.8.1 Snake bite requiring ventilatory assistance 50000

65 M4.2.8.2

Scorpion sting with myocarditis and cardiogenic shock requiring ventilatory Assistance 25000

66 M4.2.8.3 Poison ingestion/ aspiration requiring ventilatory assistance 40000

M4.3 GENERAL PEDIATRICS

RESPIRATORY

67 M4.3.1 Acute Broncho/ lobarpneumonia with empyema/ pleural effusion 20000

68 M4.3.2 Acute Broncho/lobarpneumonia with pyo pneumothorax 20000

M4.4 CARDIOVASCULAR

69 M4.4.1 Congenital heart disease with congestive cardiac failure 15000

70 M4.4.2 Acquired heart disease with congestive cardiac failure 15000

71 M4.4.3 Viral Myocarditis 15000

M4.5 RENAL

51

72 M4.5.1 Steroid Resistant Nephrotic syndrome 25000

Complicated or Resistant

73 M4.5.2 Urinary tract infection with complications like pyelonephritis and renal failure 15000

74 M4.5.3 Acute Renal Failure 10000

75 M4.5.4 Acute Renal Failure with dialysis 20000

M4.6 SEVERE ANEMIAS

76 M4.6.1 Thalassemia Major requiring chelation Therapy 20,000

77 M4.6.2 Haemophillia including Von Willibrands 20,000

78 M4.6.3 Anemia of unknown cause 10000

M4.7 INFECTIONS

79 M4.7.1 Pyogenic meningitis 35000

80 M4.7.2 Neuro tuberculosis 10000

81 M4.7.3 Neuro tuberculosis with ventilation 20000

82 M4.7.4 Enteric Fever - Complicated 10000

83 M4.7.5 Cerebral Malaria (Falciparum) 10000

M4.8 NEUROLOGY

84 M4.8.1 Convulsive Disorders/Status Epilepticus (Fits) 10000

85 M4.8.2 Stroke Syndrome 20000

86 M4.8.3 Encephalitis / Encephalopathy 15000

87 M4.8.4 Guillian-Barre Syndrome 60000

M5 CARDIOLOGY

M5.1 ACUTE MI

88 M5.1.1 Acute MI (Conservative Management without Angiogram) 20000

89 M5.1.2 Acute MI (Conservative Management with Angiogram) 30000

90 M5.1.3 Acute MI with Cardiogenic Shock 30000

91 M5.1.4 Acute MI requiring IABP Pump 50000

92 M5.1.5 Refractory Cardiac Failure 30000

93 M5.2 Infective Endocarditis 25,000

94 M5.3 Pulmonary, Embolism 30,000

95 M5.4 Complex Arrhythmias 95,000

96 M5.5 Simple Arrythmias 70,000

97 M5.6 Pericardial Effusion, Tamponade 25,000

M6 NEPHROLOGY

98 M6.1 Acute Renal Failure-(ARF) 20,000

99 M6.2 Nephrotic Syndrome 15,000

100 M6.3 Rapidly progressive Renal Failure (RPRF) 35,000

101 M6.4 Chronic Renal Failure 1 (CRF ) 15,000

102 M6.5 Maintenance Haemodialysis for CRF 10000/month

M7 NEUROLOGY

103 M7.1 ADEM or Relapse in Multiple sclerosis 20,000

104 M7.2 CIDP 8,000

105 M7.3 Hemorrhagic Stroke/Strokes 25,000

106 M7.4 Ischemic Strokes 20,000

107 M7.5 Myopathies – Acquired 15,000

108 M7.6 NEUROINFECTIONS -Fungal Meningitis 40,000

109 M7.7 NEUROINFECTIONS -Pyogenic Meningitis 25,000

110 M7.8

NEUROINFECTIONS -Viral Meningoencephalitis ( Including Herpes encephalitis) 25,000

111 M7.9 Neuromuscular (myasthenia gravis) 15,000

112 M7.10 Neuropathies (GBS) 35,000

113 M7.11 Optic neuritis 10000

114 M7.12 Immunoglobulin Therapy – IV 100000

52

M8 PULMONOLOGY

115 M8.1 Bronchiectasis with repeated hospitalisation>6per year 20000

116 M8.2 Lung Abscess ,non resolving 15000

117 M8.3 Pneumothorax ( Large/Recurrent) 35000

118 M8.4 Interstitial Lung diseases 30000

119 M8.5 Pneumoconiosis 25000

120 M8.6 Acute Respiratory Failure ( without ventilator) 25000

121 M8.7 Acute Respiratory Failure ( with ventilator) 50000

M9 DERMATOLOGY

122 M9.1 Pemphigus / 25,000

Pemphigoid

123 M9.2 Toxic epidermal necrolysis 30,000

124 M9.3 Stevens- Johnson Syndrome 20,000

M10 RHEUMATOLOGY

125 M10.1.1 SLE (SYSTEMIC LUPUS ERYTHEMATOSIS) 15,000

126 M10.1.2 SLE with Sepsis 50000

127 M10.2 Scleroderma 15,000

128 M10.3 MCTD Mixed Connective Tissue Disorder 15,000

129 M10.4 Primary Sjogren's Syndrome 15,000

130 M10.5 Vasculitis 10,000

M11 ENDOCRINOLOGY

M11.1 Uncontrolled Diabetes mellitus with infectious emergencies

131 M11.1.1 Pyelonephritis 20,000

132 M11.1.2 Lower Respiratoy tract infection 20,000

133 M11.1.3 Fungal sinusitis 40,000

134 M11.1.4 Cholecystitis 25,000

135 M11.1.5 Cavernous sinus thrombosis 40,000

136 M11.1.6 Rhinocerebral mucormycosis 40,000

M11.2 OTHER ENDOCRINAL DISORDERS

137 M11.2.1 Hypopitutarism 1,00,000

138 M11.2.2 Pituitary – Acromegaly 15000

139 M11.2.3 CUSHINGs Syndrome 30,000

140 M11.2.4 Delayed Puberty Hypogonadism 12,000

(ex.Turners synd, Kleinfelter synd)

M12 GASTROENTEROLOGY

141 M12.1 Corrosive Oesophageal injury 20000

142 M12.2 Oesophageal foreign body 5000

143 M12.3 Oesophageal perforation 25000

144 M12.4 Achalasia cardia 7000

145 M12.5 Oesophageal Varices,variceal banding 10000

146 M12.6 Oesophageal Varices, sclerotherapy 5000

147 M12.7 Oesophageal Fistula 30000

148 M12.8 GAVE (Gastric Antral Vascular Ectasia) 20000

149 M12.9 Gastric varices 15000

150 M12.10 Acute pancreatitis (Mild) 75,000

151 M12.11 Acute pancreatitis (severe) 1,50,000

152 M12.12 Acute Pancreatitis with pseudocyst (infected) 30000

153 M12.13 Chronic pancreatitis with severe pain 20000

154 M12.14 Obscure GI bleed 50000

155 M12.15 Cirrhosis with Hepatic Encephalopathy 30000

156 M12.16 Cirrhosis with hepato renal syndrome 40000

M12.17 Biliary stricture

53

157 M12.17.1 1)Post op stent 50000

158 M12.17.2 2)Post op leaks 75000

159 M12.17.3 3)Sclerosing cholangitis 75000

* 4 packages are duplicated due to overlapping specialty.

SPECIAL NOTES ON PACKAGES 1. Renal package

o AV Fistula under S9.1.1 as pre-implant procedure will be approved along with

renal transplant surgery only and not as a separate package.

o Hospital shall provide post transplant immunosuppressive therapy for 1st to 6th

month under Aarogyasri I and for 7th to 12th under Aarogyasri II.

2. Cancer package

o Chemotherapy and radiotherapy should 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 the treatment

can cause.

o The Chemotherapy packages in Aarogyasri II are only supplementary to the

packages in Aarogyasri I, hence they shall be used in association with

Aarogyasri I packages.

o Patients with hematological malignancies- (leukemias, lymphomas, multiple

myeloma) and pediatric malignancies (Any patient < 14 years of age) should be

treated by qualified medical oncologists only.

o The advanced radiotherapy packages in Aarogyasri II shall be utilized only for

the cases and diseases which do not respond to conventional radiotherapy

package provided in Aarogyasri I.

o Each cycle cost includes

Cost of chemotherapy drugs

Hospital charges

All the infusional chemotherapy cancer cases must be treated as inpatients only.

Doctors fees

Supportive care medications (i.e. I.V. fluids, steroids, H2 blockers, anti-emetics)

All Investigations o An average of Rs 2000 to Rs 5000/- has been added to the above cost, to

cover for treatment of complications.

o Tumors not included in this list, if have a chemotherapy regimen that is proven

to be curative, or provide long term improvements in overall survival will be

reviewed on a case by case basis by the technical committee of the Trust.

3. Poly trauma package Components of Poly trauma: The components of poly trauma based on the system

involved are: 1.Orthopedic trauma, 2.Neuro-Surgical Trauma, 3. Chest Injuries and

4. Abdominal injuries.

54

The above components may be treated separately or combined as the case warrants.

For providing insurance coverage to poly trauma cases requiring Hospitalization

and/or Surgery for BPL families, management of each of the above can be classified

as given below:

Orthopaedic trauma

1. Surgical Corrections Neuro-Surgical Trauma

1. Conservative 2. Surgical Treatment

Chest Injuries 1. Conservative 2. Surgical treatment

Abdominal Injuries

1. Conservative 2. Surgical treatment

I. 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.

II. In case of Neurosurgical trauma, admission is based on both Imageology

evidence and Glasgow Coma Scale (A scale of less than 13 is desirable).

III. All surgeries related to poly-trauma are covered irrespective of hospitalization

period.

IV. Initial evaluation of all trauma patients has to be free of cost.

V. The conservative line of treatment in Orthopaedics for specified procedures are

covered in Aarogyasri II.

4. Prostheses:

i) Cost of prosthesis is inclusive of foot and shoe, wherever required.

ii) Prosthesis must have been manufactured with the materials with BIS

(Bureau of Indian Standards) certification.

iii) All prosthesis shall be functional in nature.

iv) Manufacturer shall give minimum of 3 years replacement Guarantee.

v) Manufacturer shall provide free replacement of leather parts/straps etc.,

during this period apart from replacement guarantee.

55

SECTION-D(ii) FOLLOW-UP PACKAGES

FOLLOWUP PACKAGES-SURGICAL

S.No Code SYSTEM Package First

Instalment

Subsequent

3

Instalments

1 SF1.1.5.6 Total Thyroidectomy 3000 1200 600

2 SF1.4.2 Portocaval Anastomosis 10000 4000 2000

3 SF1.6.1

Operation of Adernal

4000 1600 800

glands bilateral

4 SF1.7.2

Splenorenal

10000 4000 2000

Anastomosis

5 SF1.7.3 Warren shunt 10000 4000 2000

6 SF6.8.2 Spleenectomy + Devascularisation + Spleno Renal Shunt

10000 4000 2000

7 SF6.9.1 Lap- Pancreatic Necrosectomy 8000 3500 1500

8 SF6.9.3 Pancreatic Necrosectomy (open) 8000 3500 1500

9 SF7.1.1.1 Coronary Balloon Angioplasty 10000 4000 2000

10 SF7.1.7.1 Renal Angioplasty 10000 4000 2000

11 SF7.1.7.2 Peripheral Angioplasty 10000 4000 2000

12 SF7.1.7.3 Vertebral Angioplasty 10000 4000 2000

13 SF7.2.1.1 Coronary Bypass Surgery 10000 4000 2000

14 SF7.2.1.2 Coronary Bypass Surgery-post Angioplasty 10000 4000 2000

15 SF7.2.1.3 CABG with IABP pump 10000 4000 2000

16 SF7.2.1.4 CABG with aneurismal repair 10000 4000 2000

17 SF7.2.9.1 With Prosthetic Ring 10000 4000 2000

18 SF7.2.9.2 Without Prosthetic Ring 10000 4000 2000

19 SF7.2.9.3 Open Pulmonary Valvotomy 10000 4000 2000

20 SF7.2.9.4 Closed mitral valvotomy 10000 4000 2000

21 SF7.2.9.5 Mitral Valvotomy (Open) 10000 4000 2000

22 SF7.2.10.1 Mitral Valve Replacement (With Valve) 10000 4000 2000

23 SF7.2.10.2 Aortic Valve Replacement (With Valve) 10000 4000 2000

24 SF7.2.10.3 Tricuspid Valve Replacement 10000 4000 2000

56

25 SF7.2.10.4 Double Valve Replacement (With Valve) 10000 4000 2000

26 SF7.2.19.1 Carotid Embolectomy 10000 4000 2000

27 SF8.6.4 Encephalocele 4000 1600 800

28 SF8.8.12 Surgeries on adrenal gland in Children 4000 1600 800

29 SF9.2.1 Open Pyelolithotomy 2000 800 400

30 SF9.2.2 Open Nephrolithotomy 2000 800 400

31 SF9.2.3 Open Cystolithotomy 2000 800 400

32 SF9.2.4 Laparoscopic Pyelolithotomy 2000 800 400

33 SF9.3.1 Cystolithotripsy 2000 800 400

34 SF9.3.2 PCNL 2000 800 400

35 SF9.3.3 ESWL 2000 800 400

36 SF9.3.4 URSL 2000 800 400

37 SF9.7.1 Endoscope Removal of stone in Bladder 2000 800 400

38 SF9.9.1 Transurethral resection of prostate (TURP) 2000 800 400

39 SF9.9.2 TURP Cyst lithotripsy 2000 800 400

40 SF9.9.3 Open prostatectomy 2000 800 400

41 SF10.1.1 Craniotomy and Evacuation of Haematoma �Subdural

8000 3200 1600

42 SF10.1.2 Craniotomy and Evacuation of Haematoma �Extradural

8000 3200 1600

43 SF10.1.3 Evacuation of Brain Abscess-burr hole 8000 3200 1600

44 SF10.1.4 Excision of Lobe (Frontal,Temporal,Cerebellum etc.) 8000 3200 1600

45 SF10.1.5 Excision of Brain Tumor Supratentorial 8000 3200 1600

46 SF10.1.6 Parasagital 8000 3200 1600

47 SF10.1.7 Basal 8000 3200 1600

48 SF10.1.8 Brain Stem 8000 3200 1600

49 SF10.1.9 C P Angle Tumor 8000 3200 1600

50 SF10.1.10 Other tumors 8000 3200 1600

51 SF10.1.11 Excision of Brain Tumors �Subtentorial 8000 3200 1600

52 SF10.1.12 Ventriculoatrial /Ventriculoperitoneal Shunt 8000 3200 1600

53 SF10.1.14 Subdural Tapping 8000 3200 1600

54 SF10.1.15 Ventricular Tapping 8000 3200 1600

57

55 SF10.1.16 Abscess Tapping 8000 3200 1600

56 SF10.1.17 Vascular Malformations 8000 3200 1600

57 SF10.1.18 Peritoneal Shunt 8000 3200 1600

58 SF10.1.19 Atrial Shunt 8000 3200 1600

59 SF10.1.20 Meningo Encephalocele 8000 3200 1600

60 SF10.1.21 Meningomyelocele 8000 3200 1600

61 SF10.1.25 Ventriculo-Atrial Shunt 8000 3200 1600

62 SF10.1.26 Excision of Brain Abcess 8000 3200 1600

63 SF10.1.27 Aneurysm Clipping 8000 3200 1600

64 SF10.1.28 External Ventricular Drainage (EVD) 8000 3200 1600

65 SF10.3.2 Trans Sphenoidal Surgery 8000 3200 1600

66 SF10.3.3 Trans Oral Surgery 8000 3200 1600

67 SF10.4.1 Endoscopy procedures 8000 3200 1600

68 SF10.4.2 Intra-Cerebral Hematoma evacuation 8000 3200 1600

69 SF10.7.1 Temporal Lobectomy 8000 3200 1600

70 SF10.7.2 Lesionectomy type 1 8000 3200 1600

71 SF10.7.3 Lesionectomy type 2 8000 3200 1600

72 SF10.7.4 Temporal lobectomy plus Depth Electrodes 8000 3200 1600

73 SF15.2.1.1 Stay in General [email protected]/day 8000 3200 1600

74 SF15.2.1.2 Stay in Neuro [email protected]/day 8000 3200 1600

75 SF15.2.2 Surgical Treatment (Up to) 8000 3200 1600

FOLLOWUP PACKAGES-MEDICAL

S.No Code Disease Package First

Instalment Subsequent 3

Instalments

1 MF1.1 Acute severe asthma with Acute respiratory failure

10000 4000 2000

2 MF1.2 COPD Respiratory Failure (infective exacerbation)

10000 4000 2000

3 MF4.1.12 Term baby with persistent pulmonary hypertension Ventilation-HFO Hyperbilirubinemia Clinical sepsis

6000 3000 1000

4 MF4.1.16 Term baby with seizures ventilated 5000 2000 1000

5 MF4.2.1.5 Acute Severe Asthma (Ventilated)

4000 1600 800

58

6 MF4.2.2.5 Infective Endocarditis 10000 4000 2000

7 MF4.2.3.1 Meningo- encephalitis (Non Ventilated)

6500 2000 1500

8 MF4.2.3.2 Meningo- encephalitis ( Ventilated)

6500 2000 1500

9 MF4.2.3.3 Status Epilepticus 6500 2000 1500

10 MF4.2.3.5 Intra cranial bleed 6500 2000 1500

11 MF4.3.2.1 Congenital heart disease with congestive cardiac failure

5000 2000 1000

12 MF4.3.2.2 Acquired heart disease with congestive cardiac failure

5000 2000 1000

13 MF4.3.3.1 Steroid Resistant Nephrotic syndrome Complicated or Resistant

5000 2000 1000

14 MF4.3.4.3 Anemia of unknown cause 5000 2000 1000

15 MF4.3.5.1 Pyogenic meningitis 5000 2000 1000

16 MF4.3.5.2 Neuro tuberculosis 5000 2000 1000

17 MF4.3.5.3 Neuro tuberculosis with ventilation 5000 2000 1000

18 MF4.3.6.1 Convulsive Disorders/Status Epilepticus (Fits) 5000 2000 1000

19 MF4.3.6.3 Encephalitis / Encephalopathy 5000 2000 1000

20 MF5.1.1 Acute Myocardial Infarction (Conservative management without Angiogram)

10000 4000 2000

21 MF5.1.2 Acute Myocardial Infarction (Conservative management with Angiogram)

10000 4000 2000

22 MF5.1.3 Acute Myocardial Infarction with Cardiogenic shock

10000 4000 2000

23 MF5.1.4 Acute Myocardial Infarction requiring IABP Pump

10000 4000 2000

24 MF5.1.5 Refractory Cardiac Failure 10000 4000 2000

25 MF5.2 Infective Endocarditis 10000 4000 2000

26 MF5.4 Complex Arrhythmias 10000 4000 2000

27 MF6.2 Nephrotic Syndrome 5000 2000 1000

28 MF7.1 ADEM or Relapse in Multiple sclerosis 5000 2000 1000

29 MF7.2 CIDP 5000 2000 1000

30 MF7.3 Hemorrhagic Stroke/Strokes 5000 2000 1000

31 MF7.4 Ischemic Strokes 5000 2000 1000

32 MF7.6 NEUROINFECTIONS -Fungal Meningitis 5000 2000 1000

33 MF7.7 NEUROINFECTIONS -Pyogenic Meningitis 5000 2000 1000

34 MF7.8 NEUROINFECTIONS -Viral Meningoencephalitis ( Including Herpes encephalitis)

5000 2000 1000

59

35 MF7.9 Neuromuscular (myasthenia gravis) 4000 1600 800

36 MF8.4 Interstitial Lung diseases 10000 4000 2000

37 MF8.5 Pneumoconiosis 10000 4000 2000

38 MF9.1 Pemphigus / Pemphigoid 3500 1400 700

39 MF10.1 SLE (SYSTEMIC LUPUS ERYTHEMATOSIS) 6000 2400 1200

40 MF10.2 SCLERODERMA 6000 2400 1200

41 MF10.3 MCTD MIXED CONNECTIVE TISSUE DISORDER 6000 2400 1200

42 MF10.4 MCTD MIXED CONNECTIVE TISSUE DISORDER 6000 2400 1200

43 MF10.5 VASCULITIS 6000 2400 1200

44 MF11.2.1 Hypopitutarism 8000 3500 1500

45 MF11.2.2 Pituitary - Acromegaly 6500 2000 1500

46 MF11.2.4 Delayed Puberty Hypogonadism (ex.Turners synd, Kleinfelter synd)

7000 2500 1500

47 MF12.9 Gastric varices 7000 2500 1500

48 MF12.13 Chronic pancreatitis with severe pain 7000 2500 1500

49 MF12.15 Cirrhosis with Hepatic Encephalopathy 7000 2500 1500

50 MF12.16 Cirrhosis with hepato renal syndrome 7000 2500 1500

60

MOU

(Memorandum of Understanding)

(The Insurer shall agree to abide by all the clauses in the MoU, being part of the

scheme.)

RAJIV AAROGYASRI HEALTH INSURANCE SCHEME IN THE 5 DISTRICTS OF

WEST GODAVARI, EAST GODAVARI, CHITTOOR, NALGONDA AND RANGA

REDDY (PHASE-II, 3rd RENEWAL)

MEMORANDUM OF UNDERSTANDING

This Memorandum of Understanding (hereafter called MOU) is executed at Hyderabad

on this xxth day of xx, 2010 between the Aarogyasri Health Care Trust. (Herein after

called the Trust and Party of the first part) represented by Chief Executive Officer,

Aarogyasri Health Care Trust, Dr.Y.S.R.Bhavan, Road.No.46, Jubilee Hills, Opposite

Dr.B.R.Ambedkar Open University, Hyderabad-500033.

AND

XxxxxxxxX (Insurance Company) herein after called Insurer.

Whereas the Trust has, after a due bidding process involving technical and financial

evaluation, awarded the contract of insurance under the “Rajiv Aarogyasri Health

Insurance Scheme in 5 districts of West Godavari, East Godavari, Chittoor, Nalgonda

and Ranga Reddy (Phase-II, 3rd Renewal) of the State of Andhra Pradesh for 938

identified procedures, to the Insurer and the Party of the second part.

This agreement witnesseth as follows:

A tailor-made master policy will be issued by the Insurer in favour of the Trust covering

the intended beneficiaries as described below:

1. BENEFICIARIES:

Families living Below the Poverty Line belonging to five districts viz., West

Godavari, East Godavari, Chittoor, Nalgonda and Ranga Reddy of Andhra Pradesh

PART II

61

State. The beneficiaries would be identified through the Rajiv Aarogyasri health card

issued by the Trust /white ration cards (BPL cards) issued by the Government and

data furnished to the Insurer. The total number of BPL families in the above 5 districts

as on date of publishing of the bid document is 49,49,261 (Refer to clause 7.1). The

photograph / name indicated in the Rajiv Aarogyasri Health Card (Health Card) /white

ration cards (BPL cards) will be taken as the proof for determining the eligibility of the

beneficiaries and also the identification for availing treatment under this scheme.

Such of the white ration card (BPL card) holders who are covered for the specified

diseases by other insurance schemes such as CGHS, ESIS, RTC scheme, etc. shall

not be eligible for any benefit under this scheme

2. COVERAGE:

This is a package medical insurance scheme to cover hospitalization for

surgeries and therapies through cashless treatment in respect of the following systems

and diseases.

A)

1. General Surgery 2. ENT 3. Ophthalmology 4. Gynaecology&Obstetrics 5. Orthopaedics 6. Surgical Gastroenterology 7. Cardio Thoracic surgery 8. Pediatric Surgery 9. Genitourinary surgery 10. Neuro surgery 11. Surgical Oncology 12. Medical oncology 13. Radio Oncology 14. Plastic Surgery 15. Polytrauma 16. Cochlear Implantation (Refer to

clause 2.0 B of the scheme) 17. Prostheses 18. Critical care 19. General Medicine 20. Infectious Diseases 21. Paediatric Intensive Care 22. Neonatal Intensive care 23. Paediatric General 24. Cardiology 25. Nephrology 26. Neurology 27. Pulmonology 28. Dermatology 29. Rheumatology

62

30. Endocrinology 31. Gastroenterology

B) Cochlear Implantation

Cochlear Implant Surgery with Auditory Verbal Therapy for Children below 12

years (only services will be provided by the Insurer and costs to be reimbursed by the

Trust to the network hospital on case-to-case basis). The Beneficiary under this

disease will be specifically identified after being screened by a technical committee

constituted by the Trust.

Detailed list of surgeries and therapies falling in the identified groups and packages is

given at Section–D (i) of the Part-I (scheme) above. The package rates shall be

maintained and there be any necessity to increase the package rates, the difference in

cost will be borne by the Trust.

The scheme would provide for cashless treatment to these patients who will be

admitted in the Network Hospitals in case of surgical procedures and therapies

connected with the systems / diseases / conditions mentioned above.

3. SUM INSURED:

A. The sum Insured per family shall be Rs.1,50,000/- (Rupees One lakh

and fifty thousand only). The benefit will be on floater basis, i.e., the total

reimbursement of Rs.1,50,000/- can be availed by either the individual or by the

members of the family collectively.

An additional sum not exceeding Rs.10,00,00,000 (Total Rupees Ten Crores)

shall be provided as buffer to take care of the expenses, if it exceeds the original sum.

i.e., Rs.1,50,000/- on individual/Family. In such cases only an amount up to

Rs.50,000/- to that individual/Family will be additionally provided on the

recommendation of the committee set up by the Trust.

In case of Renal Transplant Surgery with Immunosuppressive therapy for six

months, an exclusive buffer amount of Rs.1,00,000(Rupees one lakh only), will get

applied automatically without formal recommendation by the technical committee.

B. Cost for cochlear Implant Surgery with Auditory Verbal Therapy will be

reimbursed by the Trust to the Network Hospital on actual basis up to a maximum of

Rs.6.50 lakhs for each case.

63

4. PRE EXISTING DISEASES

All diseases under the proposed scheme will be covered from day one. A

person suffering from any disease prior to the inception of the policy shall also be

covered.

5. PRE AND POST HOSPITALIZATION

5.1 From screening, date of reporting to hospital up to 10 days from the date

of discharge from the hospital shall be part of the package rates. In case of Kidney

Transplantation the postoperative care have to extend to 1 year, irrespective of the

period of the policy.

5.2 Network Hospital will provide follow-up free consultation diagnostics and

medicines under follow-up packages for 125 identified procedures provided in

Section-D (ii) of Part-I. Under this package the package amount will be directly

reimbursed to the hospital by the Trust.

6. DEFINITION OF FAMILY:

Family means the group of individuals as indicated in a Rajiv Aarogyasri Health

Card / white ration card (BPL card).

7. PAYMENT OF INSURANCE PREMIUM:

It is agreed that Government shall pay to the Insurer an amount of Rs.

xxxxxxxxxx plus Service Tax as applicable, towards the entire annual premium etc.

The payment shall be made in two installments of xxxxxx plus service tax each. The

first installment will be paid before the commencement of insurance. The second

installment will be paid at the end of the six-month period.

7.1 PAYMENT / DEDUCTION OF PREMIUM DUE TO INCREASE / DECREASE IN

NUMBER OF BPL CARDS/HEALTH CARDS

The total premium payable is calculated on the basis of number of BPL families

indicated in the Bid document which is based on the data given by Civil Supplies

Department. However the additional premium may be paid or premium may be

deducted in the following manner.

a. In the case of increase in the number of BPL cards during policy period,

than that indicated in Bid, additional premium will be paid in respect of

each additional family/card at the rate of agreed premium.

64

b. In the event of reduction in the number of BPL cards than that indicated

in Bid document, premium will be deducted / refunded on the basis of

actual number of BPL cards thus reduced subject to a maximum of 10%

variance.

c. The deduction / refund in premium effected due to decrease in the

number of BPL cards / Health cards and additional premium on account

of increase in BPL Cards as provided by the Civil Supplies department

can be made in the second installment with regard to the first six months

of policy and with regard to subsequent six months of the policy within a

period of one month after the expiry of policy.

8. PERIOD OF INSURANCE

The insurance coverage under the scheme shall be in force for a period of one

year from the date of commencement of the policy (say from 00:00 hours of

05.12.2010 to midnight of 04.12.2011).

9. REFUND

If there is a surplus after the claims experience on the premium (excluding

Service Tax) at the end of the policy period, after providing 20% of the premium paid

towards the Company’s administrative cost, in the balance 80% after providing for

claims payment and outstanding claims, 90% of the left over surplus will be refunded

to the Government/Trust wit in 30 days after the expiry of the policy period.

10. ADMINISTRATION OF THE SCHEME BY THE INSURER

For the effective and successful implementation of the scheme, the Insurer shall

do the following.

A (i). Procedure for enrollment of Hospitals:

It would be the responsibility of the Insurer for enrolment of Network Hospitals

in the State of Andhra Pradesh to give adequate facilities for the treatment of the

patients when they present themselves.

The hospitals shall be separately empanelled for these phases of the scheme.

However only those hospitals having minimum of 50 inpatient hospital beds with

adequate facilities and offering the services as stipulated below shall will be

empanelled after being scrutinized and recommended by the Empanelment and

Disciplinary Committee. The minimum number of inpatient beds criteria will not be

revised from 50 during the policy period.

65

I. Definition

HOSPITAL / NURSING HOME: means any institution in Andhra Pradesh

established for indoor medical care and treatment of disease and injuries and

should be registered under APAPMCE (R&R) Act and PNDT Act (Wherever

Applicable).

II. Infrastructure and Manpower (General):

a) Should have at least 50 inpatient medical beds with adequate spacing

and supporting staff as per norms.

b) Should have Separate Male and Female General Wards.

c) Fully equipped and engaged in providing Medical and Surgical facilities for

the respective specialties.

d) In-house round the clock basic diagnostic facilities for bio-chemical,

Pathological and Radiology tests such as Calorimeter/ Auto analyzer,

Microscope, X-ray, E.C.G, USG. etc.

e) Fully equipped Operation Theatre of its own wherever surgical operations

are carried out with qualified nursing staff under its employment round the

clock.

f) Post-op ward with ventilator and other required facilities.

g) ICU facility with requisite staff.

h) Fully qualified doctor(s) of modern medicine should be physically in

charge round the clock.

i) Casualty / duty doctor / appropriate nursing staff.

j) Availability of Qualified / trained paramedics.

k) Round the clock availability of specialists in the concerned specialties

and support fields within short notice.

l) Shall be able to facilitate round the clock advanced diagnostic facilities

either In-House or with Tie-up with a nearby Diagnostic Center.

m) Shall be able to facilitate round the clock Blood Bank facilities either In-

House or with Tie-up with a nearby Blood Bank.

n) Shall be able to facilitate round the clock Ambulance facilities either own

or with Tie-up with a nearby Service Provider.

o) Maintaining complete record as required on day-to-day basis and is able

to provide necessary records of the insured patient to the Insurer or his

representative as and when required.

p) Having sufficient experience in the specific identified field.

q) Shall have all necessary infrastructure required for preauthorization

round the clock.

66

III. Infrastructure and Manpower (Specific)

a. For Empanelment of Cancer Therapy

Services of fully qualified Medical Oncologist, Radiation Oncologist

and Surgical Oncologist – all or either and equipment for Cobalt

therapy, Linear accelerator and Brachy therapy – all or either to be

empanelled for Cancer Surgeries and Chemo and Radio-Therapies.

Note: A combination of both professional and the equipment is

essential.

b. For Empanelment of Cochlear Implant Surgery with Auditory

Verbal Therapy:

Services of Qualified and Trained ENT Specialist in Cochlear

Implant Surgery and Auditory Verbal Therapist.

c. For Empanelment of Poly Trauma

Shall have Emergency Room Setup with round the clock dedicated

duty doctors of Modern Medicine.

Shall have round the clock anesthetist services.

Shall be able to provide round the clock services of Neuro-surgeon,

Orthopedic Surgeon, CT Surgeon and General Surgeon, Vascular

Surgeon and other support specialties.

Shall have dedicated round the clock Emergency theatre, Surgical

ICU, Post-Op Setup with qualified staff.

Shall be able to provide necessary cashless diagnostic support

round the clock including specialized investigations such as CT,

MRI, emergency biochemical investigations.

d. For Empanelment of Paediatric Congenital Malformations and

Post-Burns Contractures.

Shall have services of qualified specialists in the field Viz., Pediatric

Surgeon, Plastic Surgeon with dedicated theatres, post-op setup and

staff.

e. For Empanelment of Prostheses (Artificial limbs)

Shall have full time services of Orthopedic Surgeon to be empanelled to

provide prostheses package under the scheme.

Shall facilitate supply, fitting of appropriate prosthesis and gait training of

patient by physiotherapist.

Shall ensure that an appropriate prosthesis is prescribed based on

occupation of the person and standard prosthesis is supplied as per

quality norms of BIS (Bureau of Indian Standards).

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Shall also facilitate free replacement of leather parts and ensure total

replacement of Prosthesis in case of damage during guarantee period of

3 years.

and

IV. Hospital shall provide following additional benefit to the BPL

beneficiaries related to identified systems:

a. Provide space and separate Rajiv Aarogyasri counter/kiosk as per the

design for Aarogyamithras (Health Coordinators)

b. Provide Computer with networking (dedicated broadband with minimum 2

mbps speed), printer, webcam, scanner, bar code reader, biometrics,

digital camera and digital signatures.

c. Provide free food for the patient.

d. Provide transport / transportation charges for patient.

e. Free OPD consultation with separate Aarogyasri OP.

f. Free diagnostic tests and medical treatment required for beneficiaries

irrespective of surgery.

g. Provide the services of a dedicated Medical Officer to work as Rajiv

Aarogyasri Medical Coordinator (RAMCO) for the scheme and he will be

responsible to the Trust and the Insurer for doing various activities under

the scheme including Health Camps, Follow-up of referred patients from

camps, diagnosis, out-patient details, e-Preauthorization, Surgeries,

Feedback on the patient’s condition and services offered by the hospital

during hospital stay of the patients, discharges, deaths if any, follow-up

free consultation of the patients and distribution of medicines after

discharge etc. The Insurance Company shall provide CUG (Closed User

Groups) Connection to all RAMCOs.

h. Provide follow-up free consultation diagnostics and medicines under

follow-up packages for 125 identified procedures annexed at Section-D

(ii) of Part-I, the package amount will be directly reimbursed to the

hospital by the Trust.

i. Minimum one free Health Camp in village in a week for the screening of

the BPL patient suffering from the identified ailments. Hospital may have

a mobile team with diagnostic equipments and team of doctors as

specified by the Trust for this purpose. The Network Hospital shall do

documentation and other activities in health camps as per the health

camp policy of the Trust. Villages shall be identified by the Trust in

consultation with district administration and communicated to the

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hospitals/insurance company. Hospital shall provide services of

Aarogyasri Medical Camp Coordinator (AMCCO) exclusively for

organizing and coordination of health camps. The Insurance Company

shall provide CUG Connection to all AMCCOs.

A (ii) MoU with network Hospital: The Insurer shall sign MoU with all the hospitals

to be empanelled under the scheme for this Phase (Renewal). Separate MoU with

the Network hospitals with relevant provisions for Multi specialty, Cancer Treatment

and Cochlear Implantation Surgery with Auditory Verbal Therapy have to be entered

into. This MoU is subject to the approval of the Trust. Empanelled medical

institutions are supposed to extend medical aid to the beneficiary under the scheme

by following guidelines issued by the Trust from time to time. A provision will be

made in MoU of non-compliance/default clause while signing them. Such matter

shall be looked in to by the Empanelment and Disciplinary Committee consisting of

members from Trust and Insurer.

A (iii) Disciplinary actions against the hospitals: On recommendation by the

Empanelment and Disciplinary Committee the Insurer shall take disciplinary actions

against Network Hospital including De-listing from the empanelment if it is found

that guidelines of the Scheme are not followed by it and services offered are not

satisfactory as per laid down standards. Hospital may also be delisted or de-

empanelled if infrastructure in the hospital is found below the standards laid down

by Trust any time during the policy period. The Insurer is also liable for any

deficiency in the service provided by the network hospital/service provider other

than medical services and in case of any delisting the Insurer shall find an

alternative immediately.

B. Cashless Service

The Insurer has to ensure that all the Beneficiaries are provided with adequate

facilities so that they do not have to pay any deposits at the commencement of the

treatment or at the end of treatment to the extent the services are covered under the

Rajiv Aarogyasri Health Insurance Scheme. It is envisaged that for each

hospitalization the transaction shall be cashless for covered procedures. Enrolled BPL

beneficiary will go to hospital and come out without making any payment to the

hospital subject to procedure covered under the scheme. The same is the case for

diagnostics if eventually the patient does not end up in doing the surgery or therapy.

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C. Packages

The insurer should ensure that the empanelled hospitals follow the packages

worked out by the Trust. The package rates will include bed charges in General ward,

Nursing and boarding charges, Surgeons, Anesthetists, Medical Practitioner,

Consultants fees, Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical

Appliances, Medicines and Drugs, Cost of Prosthetic Devices, implants, X-Ray and

Diagnostic Tests, food to patient etc. In other words the package should cover the

entire cost of treatment of patient from date of reporting to his discharge from hospital

and 10 days after discharge after surgery including complications if any, making the

transaction truly cashless to the patient.

D. Implementation Procedure:

The entire scheme is to be implemented as cashless hospitalization arranged

by the Insurer. The following table represents the process flow of treatment to the

beneficiary:

Process Flow of the Beneficiary Treatment in the Network Hospital

Step 1

Beneficiaries approach nearby PHC/Area Hospitals/District Hospital/Network Hospital.

Aarogyamithras placed in the above hospitals facilitate the beneficiary. If beneficiary visits

any other PHC/Government hospital other than the Network Hospital, he/she will be given

a referral card to the Network Hospital after preliminary diagnosis by the doctors. The

Beneficiary may also attend the Health Camps being conducted by the Network Hospital

in the Villages and can get the referral card based on the diagnosis. The information on

the outpatient and referred cases in the PHC/AH/DH/NH and the camps will be collected

from all Aarogyamithras / Hospitals on a daily basis and captured in the dedicated

database through a well-established call center.

Step 2

The first point of contact for a patient in the hospital shall be the Aarogyamithra. The

Aarogyamithras at the Network Hospital then examines the referral card and health

card/BPL ration card, registers the patients and facilitates the beneficiary to undergo

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specialist consultation, preliminary diagnosis, basic tests and admission process.

Information like admission notes, tests done will be captured in the dedicated database

by the medical coordinator of the network hospital.

Step 3

The Network Hospital shall extend free OPD services in separate out-patient facility for

Aarogyasri beneficiaries by following the scheme guidelines.

Step 4

The Network Hospital, based on the diagnosis, admits the patient and sends e-

Preauthorization request to the Insurer and the Aarogyasri Health Care Trust.

Step 5

Specialists/Medical officers of the Insurer and the Trust examine the preauthorization

request and approve preauthorization if all the conditions are satisfied within 12 working

hours. However telephonic approval may be obtained in case of emergency cases to be

followed by regular pre-authorization.

Step 6

The Network Hospital extends cashless treatment and surgery to the beneficiary. Clinical

notes, operation notes / treatment schedule, postoperative notes etc., of the patients in

the Network Hospitals will be updated in the website by the Medical Coordinator.

Step 7

Network Hospital after performing the surgery/therapy forwards the original bills,

diagnostic reports, case sheet, satisfactory letter from patient, discharge summary duly

signed by the patient, post-operative diagnostic films, videos, acknowledgement of

payment of transportation cost and other relevant documents to Insurer for settlement of

the claim. The discharge summary and follow-up details will be a part of the Trust portal.

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Step 8

Insurer scrutinizes the bills and gives approval for the sanction of the bill and shall make

the payment within agreed period. The claim settlement module along with electronic

clearance and payment gateway will be part of the workflow in the Trust portal and will be

operated by the insurer. The reports shall be available for scrutiny in the Trust login.

Step 9

Network Hospital will provide follow-up free consultation diagnostics and medicines under

follow-up packages for 125 identified annexed at Section-D (ii) of Part-I, procedures

under the scheme and reimbursed by Trust

The diagram representing the working pattern is given at Section-B of Part-I.

E) Health Camps

Health Camps are to be conducted in all Mandal Head Quarters, Major

Panchayats and Municipalities. Minimum of 2400 camps have to be held in the five

districts in the policy year. The insurer should ensure that at least one free medical

camp is conducted by each network hospital per week at the place suggested by the

Trust. They should carry necessary screening equipment along with specialists (as

suggested by the Trust) and other para-medical staff. The Insurer shall put in the

minimum requirements as regards the health camp in the MOU with the hospitals.

They should also work in close liaison with District Coordinator of the Trust, DM & HO

and District Collector.

The Insurer should in consultation with the Trust plan, prepare and intimate the

schedule of health camps well in advance to the Trust as per the guidelines and also

inform the same to the District Collectors, DM & HOs, District Coordinators of the

Trust, Public Representatives and other stakeholders.

The Insurer should ensure that Network Hospital conducts the camp as per

schedule with all necessary equipment and professionals in the concerned fields. They

should also submit to Trust the confirmation of participation in the camps from the

Network Hospital. The Network hospital shall enter the details of the patients screened

and referred in the camps in the assigned login of the workflow of Trust Portal.

F) District Level Coordination

District level offices with necessary infrastructure have to be set-up by the

Insurance Company. The Insurer needs to have district level monitoring staff with

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district coordinators and regional coordinators (in charge of a group of Mandals within

the district). GMs/DGMs/Area Managers/Assistant Area Managers / District

Coordinators / Regional Coordinators / District Coordinators / District level doctors /

Regional coordinators of the insurance company should monitor Aarogyamithras,

coordinate with network hospital, district administration and people’s representatives

for effective implementation of programme. They should ensure that camps are held

as per schedule, arrange for canvassing for the camp, mobilize patients and follow up

the beneficiaries. He / She should work in close liaison with district administration

under the supervision of district collector. He should also ensure proper flow of MIS

and report to Trust on day-to-day basis about the progress of the scheme in the

district. The company should ensure that dedicated staff is made available for the

scheme. There shall be at least one doctor to be placed in each district. Further

wherever the concentration of the network hospitals is more additional doctors need to

be placed. The entire operation in the field should be monitored by a dedicated

department called Field Operations Support Services (FOSS) at Project Office.

Performance of all the field functionaries and the staff and managers in project office

shall be assessed periodically with definite performance appraisal system and KPIs in

e-office. The Insurance Company shall follow the instructions of the Trust in this

regard.

G) Project Office and State Level Coordination

The Insurer should nominate responsible officer/ officers to properly coordinate

work and ensure proper implementation of scheme up to the satisfaction of Trust. It

should review the progress with Trust on day-to-day basis and be responsible to

implement the suggestions of Trust for effectively running the scheme. The Project

Office of the Insurer shall be separately established at convenient place for better

coordination with the Trust. The project office shall report to the Trust on a daily basis

in the prescribed proformas. The following departments shall be established by the

Insurer in the Project Office:

i) 24 hour call center with toll free help line. The Insurer shall provide

telephone services for the guidance and benefit of the beneficiaries

whereby the Insured Persons shall receive guidance about various issues

by dialing a State Toll free number.

Call Centre Information: The Insurer shall operate a call centre for the

benefit of all Insured Persons and for real-time reporting. The Call Centre

shall function for 24 hours a day, 7 days a week and round the year. The

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Insurer undertakes to provide services to the Insured Persons in English

and local languages. The Insurer will operate a state toll free number with a

facility of a minimum of 10 lines. The cost of operating of the number

shall be borne solely by the Insurer. The Insurer will intimate the state toll

free number to all beneficiaries along with addresses and other telephone

numbers of the Insurer’s Project Office. The action taken on every call will be

routed through an escalation matrix which ends at the level of CEO of the Trust.

As a part of the Call Centre Service the Insurer shall provide the

following :

a. Answers to queries related to coverage and benefits

under the Policy.

b. Information on Insurer’s office, procedures and products

related to health.

c. General guidance on the Services.

d. For cash-less treatment subject to the availability of

medical details required by the medical team of the

Insurer.

e. Information on Network Providers and contact numbers.

f. Benefit details under the policy and the balance

available with the Beneficiaries.

g. Claim status information.

h. Advising the hospital regarding the deficiencies in the

documents for a full claim.

i. Medical and health related queries to be addressed by

medical officer in the call center.

j. Any other relevant information to the Beneficiaries including

grievances.

k. Any required information required from the field for the

Insurer.

l. Any related service to the beneficiaries.

m. Detailed MIS from Aarogyamithras in PHCs / Government

Hospitals / Network Hospitals and Camps.

n. Any related service as directed by the Trust from time to

time.

ii) MIS Department to collect, collate and report data on a real-time basis. This

department will also have a subunit with operators who collect hourly

information from the Aarogyamithras, Regional Coordinators, Team Leaders,

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Assistant Area Managers, Area Managers, Deputy General Managers, General

Mangers etc. Based on this the reverse flow of dissemination of information

shall also take place. There shall be subunits for each district. The MIS

department shall also follow-up the cases at all levels. The department shall

also generate reports as desired by the Trust. The department should have

capability to analyze the data on real time basis. They shall also use BI tools

and other statistical frame works for continuous monitoring and shall coordinate

with all other departments.

iii) Field Operations Support Services (FOSS) Department to coordinate the

daily activities with dedicated executives and managers for each district

monitoring field staff in each district consisting of Aarogyamithras, Regional

Coordinators, Team Leaders, Assistant Area Managers, Area Managers,

Deputy General Managers, General Mangers.

iv) HR Department to manage human resources for the scheme and maintain

online database of staff and their management details.

v)Training Department The insurer will arrange the workshops / training

sessions for the capacity building of the insured, their representatives and

other stakeholders in respect of the scheme and their roles at each district on

the convenience of the insured and other stake holders. The insurer shall

undertake the following training programmes for stakeholders.

o Empanelment training programme

o Network Hospital training programme at hospital

o Network hospital reorientation programme

o Induction programme

o PHC Aarogyamithras training programme

o Training Programme for Field functionaries

o Soft & Communication skills training programme

o Any other training and orientation programme designed by the Trust

vi) Publicity and logistics Department to undertake all the publicity and

logistics activities as specified by the Trust.

vii) IT Department to ensure that the website with e-preauthorization, claim

settlement and real-time follow-up is maintained and updated on a 24-hour

basis.

viii) Round-the-Clock Pre-authorization Department with specialist doctors

for each category of diseases shall work round the clock along with the Trust

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doctors to process the preauthorization within 12 working hours. The doctors

shall also undertake inspection of hospitals.

ix) Claims settlement Department with electronic clearance facilities.

x) Health Camp Department to plan, intimate, implement and follow-up the

camps as per the directions of the Trust.

xi) Grievance Department to be manned by doctors and other staff to address

the grievances from time to time as per the instructions of the Trust. The Insurer

shall act as a frontline for the redressal of Beneficiaries’ / Providers grievances.

The Insurer shall also attempt to solve the grievance at their end. The

grievances so recorded shall be numbered consecutively and the Beneficiaries /

Providers shall be provided with the number assigned to the grievance. The

Insurer shall provide the Beneficiaries / Provider with details of the follow-up

action taken as regards the grievance as and when the Beneficiaries require it

to do so. The Insurer shall also record the information in pre-agreed format of

any complaint / grievance received by oral, written or any other form of

communication.

Action Taken Report for Customer Grievance: The INSURER shall record in

detail the action taken to solve the grievance of the Beneficiaries/Provider in the

form of an Action Taken Report (ATR) within 2 working days of the recording of

the grievance. The INSURER shall provide the Trust/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 Insurer shall co-ordinate with Provider/Trust in order to solve the

grievance as and when required by the nature and circumstances of the

grievance.

xii) Follow-up Department to coordinate the follow-up consultation and

distribution of drugs as per the instructions of the Trust.

xiii) Empanelment department to empanel the hospitals in the network as

per the guidelines given by the Trust and monitor the compliance.

xiv) Feedback Department to 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

INSURER 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 INSURER at the time of

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discharge through Provider. The INSURER shall also carry out the Customer

Satisfaction Survey by using the rating card for the purpose.

xv) Administration Department for office management.

xvi) Vigilance Department for keeping vigil on all service providers and staff.

xvii) Legal Department exclusively for the project.

xviii) Accounts Department.

xix) Other departments required for Office work.

The company shall operate the above departments with definite hierarchy (Executive,

Assistant managers, Managers, DGMS, GMs, Project Officer etc) and work allocation

through e-office module for efficient, transparent and paperless office with above

departments. Performance of all the functionaries and the staff and managers in

project office shall be assessed periodically with definite performance appraisal

system and KPIs. The Insurance Company shall follow the instructions of the Trust in

this regard.

H. Aarogyamithras

i) Aarogyamithras in PHCs/ CHCs/ Area Hospitals/ Government

Hospitals etc: The unique nature of the scheme demands the Insurer to appoint

Aarogyamithras in consultation with the Trust in all PHCs, CHCs, Area Hospitals

and District Hospitals for propagating the scheme, mobilizing people for health

camps, counseling beneficiaries, facilitating the referral / treatment of these

patients and follow-up. For effective and instant communication all the

Aarogyamithras will have to be provided with cell phone CUG connectivity by the

Insurer. The Insurer will provide uniform (White apron with scheme logo) to all the

Aarogyamithras and ensure that they wear it when on duty.

ii) Aarogyamithras in Network Hospitals: The Insurer also needs to

appoint minimum three Aarogyamithras at all network hospitals to facilitate

admission, treatment and cashless transaction of patient. The Aarogyamithras

should also help hospitals in pre-authorization and claim settlement. They should

also ensure proper reception and care in the hospital and send regular MIS. The

Aarogyamithras will also ensure cashless follow-up consultation and facilitate

collection, stock maintenance and distribution of follow-up medicine in

coordination with pharmacist. For effective and instant communication all the

Aarogyamithras will have to be provided with cell phone CUG connectivity by the

Insurer. The Insurer will provide uniform (White apron with scheme logo) to all the

Aarogyamithras and ensure that they wear it when on duty. The Insurer shall

77

ensure that prefabricated Aarogyamithra kiosks with all additional requirements

as per the design approved by the Trust is put up in all hospitals. The role of

Aarogyamithra can be modified by the Trust from time-to-time. The insurer will

provide uniform and arrange the workshops / training sessions for the

Aarogyamithras on the guidelines specified by the Trust.

Performance of the Aarogyamithras both in PHCs and Network Hospitals shall be

assessed periodically with definite performance appraisal system and KPIs. The

Insurance Company shall follow the instructions of the Trust in this regard.

The detailed note on Aarogyamithras and their role is enclosed at Section-C of Part-I.

I . Online MIS and e-Preauthorization

The Insurer will post enough dedicated staff, so as to ensure free flow of daily

MIS and ensure that progress of scheme is reported to Trust in the desired format on a

real-time basis. The Insurer will establish proper networking for quick and error-free

processing of pre-authorizations. This will be done through a dedicated portal of the

Trust, the development and maintenance cost of which will be borne by the Insurer.

The source code and system design document for the application exclusively

developed by TCS Ltd. for Rajiv Aarogyasri Health Insurance Scheme shall be

provided in good working condition to Aarogyasri Health Care Trust. A dedicated data

center in the name of Rajiv Aarogyasri Health Insurance Scheme will be maintained by

the Insurer.

The preauthorization will be done in coordination with Trust i.e., by a team of

doctors from the Trust and the Insurer. The Trust will provide necessary specialists to

evaluate special cases. A technical committee consisting of specialist from

Government Sector nominated by the Trust in the concerned field, JEO (Technical) of

Trust, CMO of the Insurer and the Project Manager of the Insurer will evaluate and

recommend to the CEO of the Trust. The final decision on all the pre-authorizations

rest with the CEO of the Trust.

The website will be a repository of information and will have the following

features and the respective workflows:

1. General Information on the scheme.

2. Details of patients reporting and referrals from the PHC/CHC/Government

Hospitals/ District hospitals on daily basis.

3. e-Health Camps system and daily reporting of health camps.

4. Details of patients reporting and getting referred from the health camps.

5. e-Empanelment system.

6. Emergency approval system.

7. Call centre application.

8. Patient registration by Aarogyamithra in Network Hospitals

9. Details of in-patients and out patients in the network hospitals

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10. On-bed reporting system.

11. Costing of the Tests done in the network hospitals.

12. e-preauthorization.

13. Surgery details.

14. Discharge details.

15. Real-time reporting, active data warehousing and analysis system.

16. Claim settlement.

17. Electronic clearance of bills with payment gateway.

18. Follow-up of patient after surgery.

19. Distribution of Follow-up medicines.

20. Aarogyasri Messaging Services.

21. Enhancement workflow.

22. Grievance and Feedback workflow.

23. Bug Tracking system.

24. e-Office management.

25. Accounting system

26. TDS workflow.

27. Death reporting system.

28. Biometrics and Digital Signatures.

29. Analytical tools including BI.

J. Medical Auditors

The Insurer will appoint enough number of Medical officers who does pre-

authorization in consultation with Trust. The Company shall also recruit specialized

doctors for regular inspection of hospitals, attend to complaints from beneficiaries

directly or through Aarogyamithras for any deficiency in services by the hospitals and

also to ensure proper care and counseling for the patient at network hospital by

coordinating with Aarogyamithras and hospital authorities.

K. In-House System

The Insurer will establish in-house system to provide all such facilities

elaborated under the scheme. The Insurer will submit detailed list of staff appointed to

the Trust with their designations, responsibilities and contact numbers before the

commencement of policy.

L. Publicity

The Insurer on its part will ensure that proper publicity is given to the scheme.

Insurer will effectively use services of Aarogyamithras and District Coordinators for this

purpose. Insurer will give wide publicity through and shall submit time bound

programme:

i. Workshops and Camps.

ii. Pamphlets/Posters/Display Boards/Banners/wall paintings.

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iii. Display boards in public places and highways in the space provided by the

Trust.

iv. Guidebook: The Insurer shall handover the Guidebook and related

information to the Beneficiaries through the district administration in regional

languages preferably at the time of issuing the health cards. The Guidebook

will inter-alia contains information regarding the following:

Information regarding the Insurer and its address, fax number,

website address and other contact information.

Toll free number of the Call Centre Service.

List of Network Providers.

Information on symptoms of the diseases/systems covered along

with diagrammatic representations.

Information on the possible cure.

Information on follow-up required.

Information on possible preventive and curative measures.

Procedure to be followed by the Beneficiaries for availing the

Hospitalization Service as Cashless Access Service.

Information regarding the Policy and Benefits.

v. Theatre Slides

vi. Publicity by Aarogyasri Help Desk at the PHCs/ Aarogyasri Assistance

Counters at network hospitals.

Trust will do their part through Radio & TV.

M. Capacity Building

i. The insurer will arrange the workshops / training sessions for the capacity building

of the insured, their representatives and other stakeholders in respect of the

scheme and their roles at each district on the convenience of the insured and other

stake holders. The insurer shall undertake the following training programmes for

stakeholders.

o Empanelment training programme

o Network Hospital training programme at hospital

o Network hospital reorientation programme

o Induction programme

o PHC Aarogyamithras training programme

o Training Programme for Field functionaries

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o Soft & Communication skills training programme

o Any other training and orientation programme designed by the Trust

ii. Insurer will ensure that workshops and medical camps are organized in association

with network hospitals.

iii. The help of NGOs/SHGs will be taken by the Aarogyasri Help Desk/ Aarogyasri

Assistance Counters to spread awareness and guide the prospective patients to

the network hospitals. The Insurer will associate in this task.

11. SERVICING OF OTHER SCHEMES

The Company shall extend services for processing of claims generated through

any other scheme implemented by the Trust.

12. ACTIVITY CHART

The activity chart submitted by the Insurer as part of the bid document and

accepted by the Trust (Annexure-5) will be followed by the Insurer to take up the

activities as narrated in the scheme and MoU.

13. ASSISTANCE FROM THE GOVERNMENT

The Government will on their part render all possible assistance viz.

i. To give all necessary support for organizing sensitization programmes for the

PHCs and Government Hospitals.

ii. To extend necessary support in providing space and other support for locating

Aarogyasri Help Desks at PHCs/other Government Hospitals.

iii. To provide necessary professionals for technical committee.

14. CLAIMS PROCEDURE

The beneficiaries would be identified by the Rajiv Aarogyasri Health card/ white

ration card (BPL card) at the PHC / Government Hospital level/ Aarogyasri Assistance

Counters in the network hospital. A self-declaration by the beneficiary / patient prior to

hospitalization for the covered treatment that he does not belong to any of the

excluded categories will be a prima-facie evidence of coverage. The BPL family

member may be referred to Network Hospital by Doctors at referral points. The

treatment will be cashless for all the covered procedures. The insurer will make

payment of the claims directly to the hospital. Payments will be made to the hospitals

within 07 days after the receipt of all documents. The cost of various tests conducted

on BPL family members who ultimately do not undergo surgery, will not be included in

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the insurance cost. However Insurer will ensure that such test are done free of cost to

the patient. The claims procedure will be carried in the electronic platform of the Trust

portal. The payments to the providers will be made online through electronic

clearance. The procedure of processing of the claims will be handled by the Project

office of the INSURER.

The claims procedure will be undertaken as detailed below through electronic

platform:

i) Claim Intimation

The INSURER shall receive claim intimation from the Provider online in the

form as agreed under the scheme. The Trust portal will have reports indicating

claim intimations received.

ii) Collection of Claim documents

The INSURER shall offer a single window service at the respective Project

office to the Provider for receiving the claim documents. In case of pre-

authorization for the Cashless Service, the Network Provider will send the claim

documents along with the invoice to the INSURER. This will also follow an

electronic route.

iii) Scrutiny of Claim Documents

The INSURER shall scrutinize the claim documents at the initial stage regarding

the medical and eligibility aspect. Deficiency of any documents, if any, shall be

communicated to the Provider within 7 working days. A reminder for the same

will again be forwarded to the Provider once every 3 days of first intimation if

the deficient documents are not received or are partially received.

iv) Claim Control Number

The INSURER shall issue a claim control number online to all claims reported

for future reference purposes.

v) Payment of Claims and Claim Turnaround Time

The INSURER will settle all eligible claims and pay the sum to the Provider

within seven working days of receipt of the claim.

vi) Repudiation of claims

The INSURER on repudiation of the claim not covered under the policy, shall

mention the reasons for repudiation in writing and online to the Provider. The

INSURER shall also intimate the same to the Trust online.

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vii) Right of Appeal and reopening of claim

The Provider shall have a right of appeal to approach the Insurer if the Provider

feels that the claim is payable. If provider is not agreed with the Insurers’

decision in this regard, can appeal to the Central Committee and the decision of

the Central Committee will be final and binding on the INSURER and the

Provider. This right of appeal will be mentioned by the INSURER in every

repudiation advice as mentioned in above. The Central Committee can re-open

the claim if proper and relevant documents as required are submitted.

viii) Review of paid claims

The Central Committee will have the right to reopen a settled claim and to direct

the Insurer to settle for an appropriate amount within a period of 3 months of

payment of the claim. The Insurer further agrees to provide access to the

Central Committee their records for this purpose. All the claims settled by the

insurer to the network hospitals based on the bills received from the hospitals in

conformity with the package rate arrived at and also based on the pre-

authorization given by the company will be reckoned as final and will not be

subject to any reopening by any authority except the Central Committee for

grievances.

ix) Claim float and Bank Account

The Insurer will have a separate Bank account to pay to the Provider making a

valid claim and all payments will be electronically cleared. Detailed reports will

be made available online on a real-time basis.

x) Claims Coordination Committee

The INSURER shall form a 3 member committee (Insurer, Trust and one

service Provider nominated by the Trust) to review smooth running and

functioning of the identified activities under the chairmanship of Trust.

15. RESPONSE TIME

Authorization will be within 12 Working Hours and the Insurer shall do the

settling of claims within 7days after receipt of documents.

Insurer’s response to the Aarogyasri Scheme will be immediate through:

i. 24 hour call centre

ii. Toll free line, exclusively for this Scheme.

iii. Aarogyamithras in Aarogyasri Help Desks / Aarogyasri Assistance Counters

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iv. District Coordinators / Regional Coordinators who are nominated exclusively

for this purpose.

16. INSURER REPRESENTATIONS, WARRANTIES AND RESPONSIBILITIES

i. Power, Capacity and Authority

It has full power, capacity and authority to execute, deliver and perform this

Agreement and it has taken all necessary action (corporate, statutory or

otherwise), to execute, deliver, perform and authorize the execution, delivery

and performance of this Agreement and that it is fully empowered to enter into

and execute this Agreement, as well as perform all its obligations hereunder.

ii. Compliance with Memorandum and Articles

Neither the making of this Agreement, nor compliance with its terms will be in

conflict with or result in the breach of or constitute a default or require any

consent under.

a) Any provision of any agreement or other instrument to which such

party is a party or by which it is bound;

b) Any judgment, injunction, order, decree or award which is binding

upon such party: and/or

c) Such party’s the Memorandum and/or Articles of Association.

iii. Compliance with Laws

It has complied with all applicable Laws including but not limited to the

Insurance Regulatory and Development Authority Regulations.

iv. Risk Bearing

Trust as the buyer of insurance selected sole insurer i.e. xx Ltd as 100% risk

bearer or carrier and no other insurer is allowed to participate in this direct

insurance arrangement

v. Insurance License

Throughout the term of this Agreement, the Insurer shall continue to be an

Insurer under Law and licensed under IRDA regulations to carry on the

activities contemplated herein.

vi. Capability of Service

It is capable of servicing all the products and policies offered and also have

sufficient infrastructure, trained manpower and resources to carry out the

activities for servicing these products and policies.

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vii. Updating the list of Network Provider

The empanelment of Network Providers will be a continuous process and the

Insurer will abide by the instructions of the Trust in this regard.

viii. Disclose INSURER – Network Provider agreement

The INSURER agrees that it shall disclose to the Trust all agreements entered

into by the INSURER with any Network Provider.

ix. Steering Committee

The INSURER shall have interrelated arrangements for common activities like

empanelment of hospitals, planning for camps etc. under the scheme with the

Trust and other Insurers. A Steering Committee under the chairmanship of the

CEO of the Trust will oversee these arrangements.

x. Code of Conduct

Abide by the code of conduct prescribed by the IRDA or any other

Governmental body from time to time.

xi. No Separate Fees

No separate fees shall be charged from the beneficiaries, which it serves under

the terms of this Agreement, in respect of any policies that are being serviced

by the INSURER.

xii. Discounts and Rebates

Disclose and pass on to the Government /Trust the benefit of any discount or

rebates provided by the Network provider to the INSURER.

xiii. Run-off Period

A “Run Off period “of one month will be allowed after the expiry of the policy

period i.e., till the midnight of 04.01.2012 for 5 districts of Phase -II, 3rd renewal.

This means that pre-authorizations can be done till the end of policy period and

surgeries for such pre-authorizations can be done up to one month after the

expiry of policy period and all such claims will be honored.

17. JURISDICTION:

Any dispute arising out of this MOU shall be subject to the jurisdiction of Andhra

Pradesh.

18. NON PERFORMANCE:

Failure to perform and abide with the terms will attract the following in the event

of termination:

85

i) The Insurer will pay back to the Trust within one week the unutilized amount

of premium after settlement plus service tax.

ii) In addition to above, the Insurer will pay the total package amount for all the

cases for which preauthorization has been given, but not claimed.

iii) In addition to above, the Insurer shall pay interest at the rate of 12% per

annum on the amount refundable as determined by clauses 18 (i) and 18 (ii)

above for the period extending from the date of premium paid till the date of

receipt of refund.

19. INFORMATION FLOW:

The Insurer will ensure that the information flow takes place on a real-time

basis. The Insurer will put in and use a state of the art dedicated Internet based

network for this purpose.

20. RENEWAL

The policy may be renewed under the mutual consent of both the parties. The

premium for renewal shall be agreed upon prior to the expiry of the existing policy.

21. THE PRECEDENCE OF MoU

The MoU has precedence over other statements.

22. MODIFICATION OF MoU

The MoU may be modified as and when the need arises in mutual agreement

between the Trust and Insurer.

23. MONITORING MECHANISM:

Regular review meetings on the performance/administration of the Scheme would be

held between the GoAP / Trust and the Insurer at the District level and at the State

Level. The composition of the monitoring committees shall be as follows:

District level:

Chairman: District Collector

Members:

2. Project Director, DRDA

3. District Medical and Health Officer

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4. District Coordinator of the Trust (Member- Convener)

5. District Coordinator of Health Services (DCHS)

6. DGM/ Area manager/ Assistant Area Manager/ District Coordinator

of the Insurer

7. Representative of Zilla Samakhya.

State Level:

Chairman: CEO of Aarogyasri Health Care Trust.

Members:

2. Project Manager of the Insurer.

3. Technical Committee member nominated by the Trust.

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. The Insurer shall also put in place a mechanism of

their own to monitor the scheme on a real time basis. Detailed reports on the progress

of the scheme and issues if any emerging out of such meetings shall be reported to

GoAP / Trust.

24. GRIEVANCE MECHANISM :

District Level Committee:

Committee chaired by District Collector with following members will form the grievance

redressal cell at the district level. The decision by the committee is binding except

when an appeal to the central committee at the state level is preferred.

Members of the Committee:

2. District Coordinator of the Trust. (Member – Convener)

3. District Medical and Health Officer (DM & HO)

4. District Coordinator (DCHS)

5. Superintendent of District Hospital

6. Member from the Technical Committee (Nominated by the Trust)

7. Representative from the Insurance firm

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Central Committee:

Committee chaired by Chief Executive Officer of the Trust will entertain all the appeals

and grievances at the state level. The decision taken by the committee will be final and

binding on the both parties.

Members of the Committee:

2. Representative of the Trust

3. Technical Committee Member

4. Representative from the Insurance firm

A toll-free number will be made available at Hyderabad where any complaints can be

registered. The insurer will keep track of the complaints and report on the action taken

to the Central Committee. The beneficiaries can also send e-mail/ fax/ letter to CEO of

the Trust/ CMD’s Secretariat / Zonal Office of the Insurer. The details of toll-free

Numbers/addresses will be made available with PHCs and other Govt. hospitals. A

separate setup under the supervision of Executive Director of the Insurer at the

Corporate Office will be setup to deal with the grievances.

25. TERM & TERMINATION

1. This Agreement shall take effect on the date of signature hereof by both

Parties, and shall remain in force till the end of the policy period and the runoff

period subject to a right to the Trust to terminate the Agreement, on a review

of the performance of the INSURER before the same period. The Trust will

review the performance of the INSURER based on factors including but not

limited to:

The facilities set up and arrangements made by the

Insurer towards servicing the beneficiaries.

The extent of Network Providers;

The quality of service provided;

The beneficiaries satisfaction reports received;

Any withholding of information as sought by the Trust at the

bidding and implementation stage of the scheme; and

Such other factors as the Trust / Government deems fit.

2. This Agreement may be terminated:

a) By the Trust before the period mentioned above.

b) By both parties by mutual consent; or

88

c) Above provided it gives the other party at least 60 days prior written

notice; or

In case of termination as given above:

i) The Insurer will pay back to the Trust within one week the unutilized amount

of premium left plus service tax after settlement of claims for which the

preauthorization is given till date of termination.

ii) If the insurer fails to do as per clause above, the insurer will pay the Trust the

total package amount for all the cases for which preauthorization has been

given, but claim not settled.

3. The Trust reserves the right to re-allot the policy to any other insurer as it

deems fit for the rest of the period in the event of termination and the Insurer

shall not have any claims to it.

26. ASSIGNMENT

1. Neither party shall be entitled to assign its rights and / or obligations under

this Agreement.

2. Subject to the foregoing, this Agreement shall be fully binding upon, Inure to

the benefit of and be enforceable by the parties hereto and the respective

successors and permitted assigns.

27. ENTIRE AGREEMENT

This Agreement entered into between the Trust and the INSURER represents

the entire agreement between the parties.

28. RELATIONSHIP

The Parties to this Agreement are independent contractors. Neither Party is an

agent, representative or partner of the other Party. Neither party shall have any right,

power or authority to enter into any agreement or memorandum of understanding for

or on behalf of, or incur any obligation or liability of, or to otherwise bind, the other

party. This Agreement shall not be interpreted or construed to create an association,

agency, joint venture, collaboration or partnership between the parties or to impose

any liability attributable to such relationship upon either party.

29. SEVERABILITY

If any provision of this Agreement is invalid, unenforceable or prohibited by law,

this Agreement shall be considered divisible as to such provision and such provision

shall be inoperative and the remainder of this Agreement shall be valid, binding and of

the like effect as though such provision was not included herein.

89

30. NOTICES

Any notice given under or in connection with this Agreement shall be in writing

and in the English language. Notices may be given, by being delivered to the address

of the addressee as set out below (in which case the notice shall be deemed to be

served at the time of delivery) by courier services or by fax (in which case the original

shall be sent by courier services).

Name of the Insurer:

Attn:

E – Mail:

Fax:

31. GOVERNING LAW

The validity, performance, construction and effect of this Agreement shall be

governed by the laws of the Republic of India. Any resolution of any disputes arising

from or in connection with this Agreement, including a breach thereof, shall also be

governed by the laws of the Republic of India.

31. DISPUTE RESOLUTION

1. If any dispute arises between the parties hereto during the subsistence of this

Agreement or thereafter, in connection with the validity, interpretation,

implementation or alleged breach of any provision of this Agreement, the parties

shall refer such dispute to their respective chairmen/CEOs/CMDs for resolution. In

the event that the chairmen/CEOs /CMDs are unable to resolve the dispute within

30 days of it being referred to them, then either Party may refer the dispute for

resolution to a sole arbitrator who shall be jointly appointed by both parties, or, in

the event that the parties are unable to agree on the person to act as the sole

arbitrator within 30 days after any party has claimed for an arbitration in written

form, by three arbitrators, one to be appointed by each party with power to the two

arbitrators so appointed, to appoint a third arbitrator.

2. The law governing the arbitration shall be the Arbitration and Conciliation Act, 1996

as amended or re-enacted from time to time.

3. The proceedings of arbitration shall be conducted in the English language.

4. The arbitration shall be held in Hyderabad, India.

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This deed is executed in two originals,

both of which are operative instruments

held by both the parties.

For The Government / Aarogyasri

Health Care Trust

Chief Executive Officer

For Insurance Company.

CHAIRMAN/ MANAGING DIRECTOR

Witnesses: 1. ____________________ 2. ____________________

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BIDDING PROCESS – GENERAL GUIDELINES

1.0 Procedure for Evaluating Bids / Proposals

The bids received within stipulated period and collected in Tender Box are opened in

the presence of Company Representatives. First the Larger Covers are opened and

then Technical and Financial Proposals will be segregated. Then the Technical

Proposals will be opened in the presence of Company Representatives and will be

evaluated by Technical Committee nominated by Trust / GoAP. Once the technical

bids have been evaluated, the successful bidders will be informed about the date of

opening of financial bids. Financial bids of only those bidders will be opened who are

declared successful in the technical Bid Evaluation stage. Financial bids will be

opened in presence of the representatives of insurance companies that have been

declared successful in the technical bid evaluation stage. Then Financial Bids will be

evaluated by Financial Committee nominated by Trust / GoAP.

2.0 Award of Contract

Government of Andhra Pradesh/Trust shall award the contract to the

successful bidder/s whose Bid has/ have been determined to be substantially

responsive, lowest evaluated bid, provided further that the bidder has been determined

by the Government of Andhra Pradesh / Trust to be qualified to perform the contract

satisfactorily.

3.0 Right to negotiate at the time of Award

Government of Andhra Pradesh/Trust reserves the right to negotiate starting

with lowest bidder after opening the Price Bid.

4.0 Government of Andhra Pradesh /Trust’s Right to Accept or Reject any or all Bids:

Government of Andhra Pradesh / Trust reserves the right to accept or reject

any Bid or annul the Bidding process and reject all Bids at any time without assigning

any reason prior to award of contract, without thereby incurring any liability to the

affected Bidder or Bidders. Government of Andhra Pradesh/Trust is not bound to

accept the lowest or any bid.

Incomplete bids and financial bids with extra attachments are liable to be

disqualified.

PART- III

92

5.0 Notification of Award and Signing of MOU:

The Notification of Award will be issued with the approval of the Tender

Accepting Authority. The terms of MOU are non-negotiable and the successful

insurance company shall sign the MOU proposed by GOAP/Trust at part II of the

document in duplicate within 24 hours of declaration of ‘award of contract’, failing

which the contract may be offered to the next bidder in order of merit. Once the MOU

is signed, the insurer will have no right to cancel the MOU signed between the GoAP

/Trust and insurer.

6.0 Canvassing

Bidders are hereby warned that canvassing in any form for influencing the

process of notification of award would result in disqualification of the Bidder.

7.0 Amendment of Bid Documents

a) At any time prior to the deadline for submission of bids, the GOAP / Trust

may, for any reason modify the Bidding documents, by amendment.

b) The amendment will be notified in writing /by e-mail/ by fax or telegram to all

prospective bidders who have purchased the Bidding documents and

amendments will be binding on them.

c) In order to afford prospective bidders reasonable time to take the

amendment into account in preparing their bids, the purchaser may, at its

discretion, extend deadline for the submission of the Bid.

NOTE: Oral statements made by the Bidder at any time regarding quality of service or

arrangements of any other matter shall not be considered.

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SUBMISSION OF TECHNICAL AND FINANCIAL BIDS

The Government of Andhra Pradesh / Aarogyasri Health Care Trust seeks detailed bid documents from insurance companies interested in implementing “Rajiv Aarogyasri Health Insurance scheme for 938 procedures in 5 districts of Phase-II (3rd renewal) of Andhra Pradesh.

1.0 Submission of Proposals:

The bidder must submit the proposal in both hard and soft copies as per the details

mentioned below:

i. Technical proposal in both hard and soft format should be sealed in a separate

envelop clearly marked in BOLD “SECTION A & B – “TECHNICAL PROPOSAL FOR RENEWAL OF RAJIV AAROGYASRI HEALTH INSURANCE SCHEME IN 5 DISTRICTS (PHASE II – 3rd RENEWAL)” written on the top of the envelope.

Under no circumstances shall the financial quote appear anywhere in Technical Bid and technical bid shall stand rejected if quoted”.

ii. Financial proposal in both hard and soft format should be sealed in another

envelop clearly marked in BOLD “SECTION C – FINANCIAL PROPOSAL FOR RENEWAL OF RAJIV AAROGYASRI HEALTH INSURANCE SCHEME IN 5 DISTRICTS (PHASE II – 3rd RENEWAL) ” written on the top of the envelope.

iii. Both envelops should have the bidders Name and Address clearly written at the

Left Bottom Corner of the envelope. iv. Both envelops should be put in a larger cover / envelop, sealed and clearly

marked in BOLD have “SECTION A & B – “TECHNICAL PROPOSAL FOR RENEWAL OF RAJIV AAROGYASRI HEALTH INSURANCE SCHEME IN 5 DISTRICTS (PHASE II – 3rd RENEWAL) ”

“SECTION C – FINANCIAL PROPOSAL FOR RENEWAL OF RAJIV AAROGYASRI HEALTH INSURANCE SCHEME IN 5 DISTRICTS (PHASE II – 3rd RENEWAL) ”

written on envelop and have the bidders Name and Address clearly written in BOLD at the Left Bottom Corner.

v. The bids may be rejected and not evaluated if the bidder fails to:

a. Clearly mention Technical / Financial Proposal on the respective envelops.

b. Seal the envelope properly with sealing tape. c. Submit both envelops i.e. financial proposal and Technical Proposal

together keeping in large envelop. d. Give complete bids in all aspects. e. Submit financial bids in the specified proforma (Section C). f. Submit soft copies of financial proposal and Technical Proposal in

respective covers. g. Label the covers as indicated above.

PART IV P

ART-IV

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2.0 Signature in each page of document

The competent authority of the Bidder must sign each paper of Bid Document.

Any document / sheet not signed may lead to rejection of Bid.

3.0 Deadline for Submission Bids / Proposals:

Complete bid documents should be received at the address mentioned below

not later than 12.00 noon on 1st November 2010. Bid documents received later than

the prescribed date and time will not be entertained under any circumstances.

Address:

Chief Executive Officer Aarogyasri Health Care Trust Dr.Y.S.R.Bhavan, Opposite Ambedkar Open University, Road.No.46,

Jubilee Hills, Hyderabad – 500 033 Phone: 040 – 23148000 Fax: 040 – 23148100 E-mail: [email protected]

4.0 Sections of the bid document:

The bid documents should be both in hard and soft form and should include the

following:

SECTION A – GENERAL INFORMATION AND UNDERTAKING BY THE BIDDER in the prescribed proforma enclosed. SECTION B

(i) Qualifying Criteria (Annexure –1)

Insurance company having full fledged establishment with experience in

conceptualizing, designing and implementing large healthcare schemes both in

Government and private and registered with IRDA. The Insurance Company must

have serviced at least 20 lakh beneficiaries in a single policy related to health

insurance (Details to be given in Annexure 2a and 2b).

The qualifying requirements data shall be enclosed with the Technical Bid

only. The bidders who do not qualify the above criteria, will be disqualified

immediately and their bids will not be considered

mailto:[email protected]

95

(ii) Experience in Government run/sponsored HI Schemes. (Annexure –2a)

Insurance Company shall spell out No. of in either Central or State Government

run/sponsored schemes it is handling/handled successfully in relation to Health

Insurance in prescribed Annexure 2a. Details of the schemes can be elaborated if

desired.

(iii) Experience in Non Government Group Insurance Policies related to Health Insurance Schemes. (Annexure –2b)

Insurance Company shall spell out No. of large Group Insurance Policies

successfully being serviced and also serviced in the past in relation to Health

Insurance shall be submitted in prescribed Annexure – 2b. Details of the schemes can

be elaborated separately if desired.

(iv) Tailor-made Policy (Annexure –3)

Insurance Company shall submit draft tailor made policy based on the

schemes mentioned in the document.

(v) Office Infrastructure (Annexure –4)

Company shall submit the details of office infrastructure in the state and in the

concerned districts in Annexure 4. A detailed organogram with existing manpower may

be attached apart from the annexure if desired.

(vi) Activity Chart (Annexure-5)

The scheme covering all the BPL population needs to be launched within time

frame. Hence the Insurance Company shall submit a time bound action plan, not

exceeding the date of launch, in Annexure – 5 to mobilize sufficient infrastructure and

manpower as per the requirement

(vii) Plan on Health Camps (Annexure-6)

The bidder shall give a detailed action plan on organizing health camps as

prescribed in para 18 D of part I.

(viii) Empanelled Health Facility with the Bidder (Annexure-7)

Fresh empanelment of network hospitals has to be done for this Phase. Hence

the number of specialty hospital already empanelled with the Insurance Company in

running other schemes in the State and concerned Districts shall be given in

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Annexure-7. Insurer shall enumerate only those hospitals having requisite

infrastructure as per the scheme. Detailed list may be attached if required.

(ix) Details of disqualifications, terminations and litigations against the Bidder

(Annexure-8)

The bidder shall provide full information regarding any disqualification,

terminations and litigations, past and present, initiated against the company. Non-

disclosure of any such act against the company and found subsequently by the Trust

will attract disqualification and termination at any point.

(x) Other Information, if any. (Annexure-9)

Any other information Insurer desires to inform, which is relevant to the scheme.

NOTE: Bidder shall give point wise reply of the tender document for agreement /

disagreement and attach the necessary annexures as mentioned above.

97

TECHNICAL BID

SECTION A

GENERAL INFORMATION

DECLARATION BY THE BIDDER

I, _________________________________ Designated as _______________ at_____________________________ of ___________________________ Insurance Company hereby declare that I have read the contents of the tender document consisting of Part I to IV and having agreed to the contents here by submit the bid in the desired format with respective proformas duly signed by me. If our bid is found successful, the company is agreeable to execute the MoU as given in part II with in twenty four hours (excluding public holidays) after the award.

DATE: AUTHORIZED SIGNATORY

1 Name of the Insurance Company

2 Address of Head Office

3 Name and designation of the person submitting the

proposals

4 Status

Public Sector/ Private Sector

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SECTION –B

Please submit the following:

Annexure-1 Qualifying Criteria: IRDA license attached

No.

Date of Expiry:

Annexure-2a Experience: Government (Only Health Insurance Policies having 20 lakh beneficiaries)

Attach copy of Policy Documents

Annexure-2b Experience: Non-Government (Only Health Insurance Policies having 20 lakh beneficiaries)

Attach copy of Policy Documents

Annexure-3 Draft Policy

Annexure-4 Office Infrastructure

Annexure-5 Activity Chart

Annexure-6 Plan for Health Camps

Annexure-7 Empanelled health facilities:

With Insurer(Only those hospitals having requisite infrastructure as per the scheme)

50 bedded hospitals with requisite infrastructure

Annexure-8 Details of disqualifications, terminations and litigations against the Bidder

Annexure-9 Other information, if any

99

Annexure-1

Attach attested copy of IRDA license

Annexure-2a

Experience in Group Health insurance of the Company in India Government Schemes

Name of the Scheme

No. of Families

No, of Beneficiaries

Per Capita Benefit

Amount of Claims

reported for the period

Government of India/Name of

the State

100

Annexure – 3

Attach Draft Policy in conformity with the Scheme.

Annexure-4

Annexure-2b

Experience in Group Health insurance of the Company in India Non-Govt. Schemes

Name of the Organization

Brief Details of

the Scheme

Period of Cover

No. of Families

No. of Beneficiaries

Amount of Claims reported for the

Period

Office Number of Branches

All India State District

West

Go

davari

East

Go

davari

Ch

itto

or

Nalg

on

da

Ran

ga R

ed

dy

Head Office

Zonal Offices

Operating Offices

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Annexure-5

Activity Chart

Activity Number of days required to complete the activity from the award date

Remarks

Identifying the Project Officer

Setting up of Project Office with infrastructure

Appointment of Medical Officers

Establishment of other staff

Preparatory meeting with hospitals

Inspection of hospitals vis-à-vis scheme requirements, identification of Rajiv Aarogyasri Medical Coordinator (RAMCO), Aarogyasri Medical camp Coordinator (AMCCO), signing of MoU and Empanelment Of Hospitals

Issue of CUG connections to RAMCOs and AMCCOs

Installation of kiosk, computer and accessories and 1mbps connectivity.

Printing and distribution of publicity material

Printing and distribution of stationary related to work flow of the scheme.

Appointment of Aarogyamithras

In PHCs/Govt.Hospitals

In Network Hospitals

Training of Aarogyamithras, distribution of Aprons and CUG mobiles.

Training of Doctors

Training of other staff

IT enabling

Establishment of 24 Hrs Call Center

Establishment of other infrastructure

Establishment of infrastructure in the districts

Preparatory meetings and trainings at district level for inaugural mega-camps.

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Annexure-6

Plan for Health Camps

Annexure 8

Details of disqualifications, terminations and litigations against the Bidder

Annexure 9 Any other information

Annexure-7

Health Facilities with Insurers

District wise No. of Hospitals (Tertiary Care)

No. of General Hospitals

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SECTION C – FINANCIAL PROPOSAL

A) Premium quote for a sum insured of Rs. 1.50 Lakh per family on floater basis:

S.NO. No. of FAMILIES

PREMIUM PER FAMILY

TOTAL PREMIUM WITHOUT S.T.

TOTAL PREMIUM WITH S.T.

1 49,49,261 Rs. Rs. Rs.

B) Premium quote for Rupees 10 Crores as buffer / corporate sum insured. A sum of

Rs. 50,000 can be availed by the individual if it has consumed the basic sum insured

of Rs. 1.50 lakh. This is subject to the case being recommended by the Committee

appointed by the Trust and to the availability of balance amount in buffer account.

BUFFER AMOUNT PREMIUM WITHOUT S.T. PREMIUM WITH S.T.

Rs. 10 Crores Rs. Rs.

Total Premium without S.T.: (A + B) =

Total Premium with S.T.: (A + B) =

C) Details of Add on cover without any additional premium:

S. No. Benefits Details

1

2

3

4

Note: No other documents or attachments are permissible along with Section C. Any deviation will attract disqualification.