Improve the quality of life through various healthcare initiatives thereby reducing the severity of poverty resulting from health related catastrophes
Provide quality Healthcare services at affordable costs
Community Development through Health education on Preventive Health, Nutrition and Sanitation
Proposed Model Network Partners Network the Hospitals at Mandal Level Super Specialty hospitals at Dist level Tie-up with NWH to provide consultation by Lady Doctor at PHC once in a week.
Benefits Preventive Healthcare- Community Development, Education on Nutrition and Sanitation Medical Conditions Free OPD consultation, Discount on Drugs & Diagnostics Surgical Conditions At Village level through Heralth Assiastants and Health Workers Refferal Hospitals Referral Hospitals Referral Hospitals
Hospitalization Cover for Medical Conditions admission for family
Community Development Activities
Treatment to be taken at Network Hospitals Only
Treatment in General ward only
Out Patient Consultation PHC level: consultation with lady doctors once in a week Network Hospital (NWH): consultation free of cost Diagnostics: Basic diagnostics will be done at PHC level free of cost Diagnostics at NWH will be done at a fixed discounted rate. Quality Medicines 1. Free of cost at PHC level 2. Discounted rate at NWH ( drug depots of Velugu) Services under the Scheme
Medical and Secondary and Tertiary Surgical Care: through Referral Network Hospitals, up to a maximum amount of 30000/- Covers more than 1650 surgeries –includes all categories of complex and common surgeries, OBG – includes normal delivery, LSCS and Hysterectomy General Surgery Gastroenterology Orthopaedics – includes fracture surgeries Genito-Urology Endocrinology ENT. 100% Cashless facility
Hospitalization cover: Family floater hospitalization policy Cover- Inpatient treatment requiring hospitalization for more than 24 hours. Maximum amount payable is Rs 5000/- under the Family Package 4. Cover would include consultation, investigation and room charges, medicines and consumables. Bed charges, doctor fees and Investigation charges will be fixed. 10% of Co-Payment on the final bill.
Benefits OPD Medical Admission Surgical Treatment Doctor’s fees Free Free Free, Included in package Length of stay 2 Admission/Family Till fit for discharge Medicines /consumables Buy from Biocare or NWH Pharmacies Included in the Package Free, Included in Package Investigations Pay discounted rates Included Free, Included in package Bed charges included Included in package Oxygen, ventilator etc Beneficiary to pay for Included in package Nursing charges Included Included What do you pay for? OPD diagnostics oxygen Ventilator & other exclusions 10% of the final bill Non-medical expenses, Implants like stents, valves & Other exclusions
Comparison with other Insurance Schemes Other insurance schemes Our Scheme Premium Approx 1000 < Rs 260/- Pre-existing diseases Not covered Covered Coverage Upto 1 lakh ? 30000 OPD paid Free Diagnostics Paid at hospital rate Approz 50% discount Medicines Buy at market rate Buy from NWH pharmacy at discounted rate or Velugu Drug Depots
Implementing Agency (Zilla Samakhaya will act as TPA)
The ZS is responsible for the day-to-day operation of the Scheme. The duties will include, Ensure service standards at provider Network for hospitalization and Diagnostics
Maintaining member database
Arrange for cashless treatment for the beneficiary in
Network Hospital by issuing pre-authorization
Claims Processing and settlement
Maintenance of accounts
Generation of periodic report on utilization (statistics)
Administer the scheme, avoiding misuse and fraud
Appoint required manpower to monitor, manage and maintain the scheme.
PHC/Network Hospitals: PHCs and Hospitals enrolled under the scheme to provide services to the members of the scheme. Responsibility: Quality Treatment to members Free Consultation and Discounted Investigations
Hospital Accreditation Process Flow START STOP Hospital approaches ZS with application Inspection of Hospital facilities by ZS Representatives Representative forwards recommendation to IKP Site visit and Inspection by IKP Evaluation of the Hospital as per the Standards of accreditation Generation of the Inspection report on Services and facilities Submission of Report to Committee (IKP +ZS) Final approval from Committee Formal tie-up of the hospitals tripartite agreement Training of Hospital co-coordinator regarding the Protocol Updating of Database Communication to IKP/ZS MMS/VO HSC
Village Organization will take the responsibility of Enrollment
VO will collect the Enrollment from and Premium from the member and deposit with the Mandal samakhaya, hence MS will collect the premium of their Mandal and deposit with ZS
ZS will issue ID cards in 15 days time to MS. MS will issue them to VO. VO will issue the cards to the members.
As soon as members get the ID card they can avail the treatment at NWH
STOP START VO Representatives deposits the Fee to MS or ZS Bank account Generation of Photo ID Cards and covering letters VO Reps forwards enrollment forms to ZS Data from Enrollment form entered into software Attestation by VO Representative. Issuance of Receipt to member Collection of Fee and photograph taken Distribution of ID to members by VO Reps Dispatch of ID Cards to VO Reps Enrollment Filled by Member
Availing the Treatment Beneficiary goes to Network hospital with ID Card, Receipt Admission for Surgery CASHLESS Hospitalization Admission for Medical treatment Patient pays only 10% of co-payment Member signs on the Claim Form START Discharge Intimation to ZS by NWH Pre-Authorization- from ZS Free OPD Consultation Investigation Special rates
Preauthorization Method: When a beneficiary is advised surgery/medical treatment by NWH, the Hospital sends a Pre-authorization to the ZS office seeking approval to conduct the surgery under the Scheme. The medical officer at the ZS approves the Preauthorization if all documents and requirement is in order. In case of emergency, the Coordinating Officer at NWH shall take verbal sanction from the Implementing Agency and proceed with the surgical/medical treatment. The preauthorization for the same shall be sending to the Implementing Agency within 24 hours. Documents to be sent: Photocopy of the ID Card
Preauthorization Flowchart General Exceptions Sent to Hospital for supporting reports verification Eligibility Yes Complicated cases Eligible No Receive of Intimation from Hospital Generation of Pre-Authorization Serial No. Sent to VO Rep for verification A-Eligibility Verification ID card, Receipt, Residential Proof B-Medical verification Data entry into Software START STOP Letter of Rejection to Hospital Authorization letter to hospital Medical Officer checks and fixes rate Letter of Rejection to Hospital NO Complicated/General/ Exceptions
The Claim Form from the Hospital should be accompanied by
Photocopy of the I.D. Card
Original claim form with the signature of the beneficiary.
Final split – up bill – with the signature of the beneficiary raised in the name of “ZS.”
Original authorization issued by ZS
Original discharge summary
Operation Note from treating Doctor (Incase of surgery)
Original Investigation and Lab Reports
List of consumables prescribed
Claims Flowchart Receipt of claims From NWH Communication To Hospital Communication To Hospital Claim ID Generation Document verification Medical Scrutiny and Claims Processing Approved Claims Outward Letter Of Settlement To the Bank By ZS Claim pending for supporting Documents Collection of DD Dispatch o hospital Complete Incomplete
Periodic quality check of Labs and Hospital service audit will be carried out by the ZS. Continuous failure to keep prescribed standards and conditions set by the ZS would result in disciplinary action against the NWH and Lab
All Network Hospitals (NWH) shall display a board with “Scheme Name” in Telugu prominently at the reception.
Under the scheme, the beneficiaries are entitled to Free Out Patient services. No amount shall be collected as Registration Charges or Consultation Charges. On no account shall any amount be collected from the individual beneficiaries when admitted for surgical procedure
The package rates mentioned are all exclusive of the implants and the prosthesis.
The beneficiaries under the Scheme will be entitled only for General Ward Admission
OPD Record Investi gations Specialty Address Age/ Sex ID No Name of Patient S. No
Surgery Statistics Report Date: Amount Pre-autho No. Specialty Name of surgery Date of Admission Address Age& Sex ID No Name S No
OPD Statistics Weekly Report Name of the Hospital Place Statistics From: To:
IPD Weekly Statistics Report Name of the Hospital : District :- Surgery Statistics From: To: No. of surgeries/Medical Admissions performed for the current week :-