Cm health insurance scheme

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Cm health insurance scheme

  1. 1. WWW.CMCHISTN.COM CHIEF MINISTER’S COMPREHENSIVE HEALTH INSURANCE SCHEME
  2. 2. CHIEF MINISTER’S COMPREHENSIVE HEALTH INSURANCE SCHEME CMCHISTN PORTAL INFORMATION BOOKLET WWW.CMCHISTN.COM
  3. 3. GOVERNMENT OF TAMIL NADU THE CHIEF MINISTER’S COMPREHENSIVE HEALTH INSURANCE SCHEME INTRODUCTION OF CMCHIS THROUGH WEB PAGE DETAILS OF THE SCHEME WEBSITE: This is official website of CMCHIS Website id – www.cmchistn.com This page consists of eligibility, salient features, contact details, list of network hospitals, list of diagnostic centers, package rates for procedures, member ID, claims, tender, circular & guidelines, smart card and member search. The web page has 24 hrs toll free contact number at the right top 1800 425 3993 which caters any queries and complaints from public, scheme members, hospitals and other stake holders. A continuous scrolling is running regarding weekly Monday grievance meeting at TNHSP chaired by The Project Director in regard to any issues pertaining to complaints, grievances, grading, empanelment of hospitals etc., is available. This web page also contains the details about the awards recently got by the scheme  Recognition award from the honorable Chief Minister of Tamil Nadu.  eIndia award for “Best practices in Health Insurance”
  4. 4. MEMBER ELIGIBILITY ELIGIBLE MEMBERS:  The family income of less than 72,000 who are all residing in State of Tamil Nadu  Srilankan refugees, differently abled, farmer welfare scheme members, OAP pensioners are also covered.  And such persons who may be declared to be eligible for coverage under the “Chief Minister’s Comprehensive Health Insurance Scheme” by the Government. Eligibility is verified by : 1. Those who are having new CMCHIS smart card 2. Member with erstwhile scheme smart card (KKT) 3. The details are available both in English and vernacular language.
  5. 5. SALIENT FEATURES OF THE SCHEME SCHEME HIGHLIGHTS: More than 1.34 cores of family covered under this CMCHIS scheme (i.e.) nearly around 50% of population of Tamil Nadu. Insurance coverage of 1 lakh is provided for each family per year for a period of 4 years . For a specific 77 procedures an Insurance coverage of 1.5 lakhs is provided for the treatment. Around 1016 procedures is covered which includes medical, surgical, emergency, trauma care, pediatric and neonatal specialities. Five high end procedures:  Renal transplant  Liver transplant  Bone marrow transplant  Stem cell transplant and  Cochlear implant. For the above five high end procedures, the insurance company will be paying 1.5 lakhs and the remaining over and above the insurance coverage money will be paid by the Tamil Nadu Health Systems Projects in order to support the scheme member to undergo these high end Procedures in an entirely cashless way. For this benefciaracry need to appear before specialist committee at TNHSP 23 stand alone diagnostic procedures and 113 medical and surgical follow up are being covered. Instruction, guidelines booklet about the scheme is available in a downloadable format in this tab.
  6. 6. STAKE HOLDERS & STAFF CONTACT DETAILS CONTACT DETAILS OF:  The Project Director, TNHSP  UIIC officials – Implementing agency  Chief Medical officer of preauth, claims  Hospital and District wise liaison officers, district project officers and district coordinaors with contact details are available.  This tab is in use to enable easy access for beneficiraies and for the hospitals in regard to all the scheme related activities.
  7. 7. NETWORK HOSPITALS
  8. 8. HOSPITAL LIST : The tab has single and multi speciality empaneled hospitals in drop downs. This tab also includes the grading criteria for empanelment of hospitals as a network hospitals in the scheme Each individual hospitals contains individual score, grade and specialities available in the concerned hospital. Hospital wise and district wise data can be viewed. Single speciality hospitals are graded as S1 & S2 , Mutli speciality are graded from A1 to A6. So far in this scheme we have empaneled 120 Government hospitals includes Government medical colleges and 697 private hospitals. DIAGNOSTIC CENTRES
  9. 9. DIAGNOSTIC CENTERS: In our scheme we have included 23 stand alone diagnostic services to the beneficiaries for the purpose of investigations. This tab also provides details about the diagnostic centre guidelines for Government medical officers ,who are referring the patients for investigations. Diagnostic referral form is also included in a downloadable format in this tab for specified procedure. Diagnostic centers can be surfed District wise and procedure wise PACKAGE RATES: Packages for all the medical, surgical, follow up, diagnostic procedures are available in the website The rate varies from A1 to A6 hospitals and S1 to S2 hospitals based on the grading The procedure cost for A1 to A6 and S1 to S2 hospitals are available Each procedure are given with unique package codes for easy identification of speciality, generation of MIS and for performance monitoring Speciality wise and procedure wise details can be checked from the scheme portal.
  10. 10. PREAUTH & CLAIMS LOGIN: LOGIN:  The user id and password for login given to every stake holders of the scheme.  The scheme is entirely paperless.  Preauth, claims, electronic transfer of claims money to the NWH are done through this login. DASH BOARD:  Dash board widget is available which shows the recent update of pre-auth submitted and approval given, claims submitted and approval, age wise, gender wise, district wise performances, e-payment of claims money settled to network hospitals and taluk wise distribution of smart cards.
  11. 11. SPECIALITY WISE DETAILS Chief Minister's Comprehensive Health Insurance Scheme Period From 11-01-2012 Speciality_Preauth Appr. Summary_02.06.2013 S.No. Speciality / Package Appr. Nos. App. Amount In Crores / Lakhs 1 CARDIAC VALVE REPLACEMENT SURGERIES 4,807 46.87 2 CARDIAC BY PASS SURGERIES 4,323 41.35 3 CONGENITAL CARDIAC DISEASE 4,909 38.02 4 CARDIAC STENT FOR HEART ATTACK 5,126 34.65 5 KNEE REPLACEMENT 5,193 34.13 6 KIDNEY STONE SURGERY 17,693 33.73 7 NEW BORN DISEASES 12,688 33.48 8 CANCER - RADIOTHERAPY 14,618 33.09 9 SPINAL SURGERY 7,410 25.78 10 CANCER - CHEMOTHERAPY 46,685 25.68 11 KIDNEY DISEASE - DIALYSIS 31,045 25.21 12 HEARING AID 30,519 24.72 13 CANCER 6,842 20.83 14 HIP REPLACEMENT 2,375 17.66 15 FRACTURE 8,996 17.08 16 PLASTIC SURGERY 7,225 16.86 17 EYE SURGERY LIKE RETINAL SURGERY 11,561 16.27 18 HYSTERECTOMY 8,833 14.71 19 HEART ATTACK MEDICAL MANAGEMENT 6,515 14.44 20 VASCULAR SURGERY 3,902 13.94 21 GIT - SURGERY 4,791 13.3 22 STROKE MANAGEMENT 6,316 10.96 23 PROSTATE SURGERY 4,821 10.39 24 NEUROSURGERY 2,121 9.55 25 CARDIAC ARRHYTHMIAS MANAGEMENT 1,234 9 26 LAVH 5,255 7.76 27 GYNAEC SURGERY 3,121 7.73 28 BURNS 1,958 6.29 29 RENAL TRANSPLANTATION 444 6.17 30 HYSTERECTOMY FOR CANCER 1,801 5.2 31 EYE SURGERY-ADULT GLAUCOMA 4,361 5.06 32 BLOOD CANCER 4,865 4.87 33 INTERVENTIONAL RADIOLOGY 595 4.76 34 BREAST CANCER 2,318 4.63 35 PAEDIATRIC CONGENITAL MALFORMATIONS 1,118 3.71 36 DENGUE SHOCK SYNDROME 1,798 3.35 37 THYROID SURGERY 1,502 3.02 38 BRAIN TUMORS 372 2.01
  12. 12. 39 EPILEPSY SURGERY 162 1.89 40 EYE SURGERY-PAEDIATRIC CATARACT 1,153 1.7 41 COCHLEAR IMPLANT SURGERY 111 1.66 42 SQUINT SURGERIES 1,177 1.36 43 EYE SURGERY-DIABETIC 2,751 0.52 44 HYSTERECTOMY - PREGNANCY RELATED 101 0.25 45 THALASSEMIA CHELATION THERAPY 490 0.21 46 STEM CELL TRANSPLANTATION 14 0.2 47 BONE MARROW TRANSPLANTATION 9 0.11 48 EYE SURGERY-PAEDIATRIC GLAUCOMA 50 0.07 49 LIVER TRANSPLANTATION 4 0.05 50 OTHER 59,078 124.26 Grand Total 3,55,156 778.54  This is the table regarding all the specialities.  This will benefit the public for the required treatment under this scheme.  This tabular column represents each and every speciality with specified no’s and the amount. Generated from MIS CIRCULAR & GUIDELINES CIRCULAR AND GUIDELINES:  The Government orders, guidelines and minutes of the meeting held with Deans of Medical colleges, CMO’s/HS of Government hospitals are available and updated as and when required under this tab. The following GO’s for Government Hospitals are mentioned below are already available in the portal for reference: 1. Guidelines for the Creation of Insurance Wards in Government Hospitals G.O (Ms).No.127 Dated on 10.04.2012 2. Creation of Corpus Fund under TNCMCH, G.O (Ms).No.320 dated on 19.11.2012.
  13. 13. PREAUTH PREAUTH INBOX (GRID PAGE) INDIVIDUAL PATIENT WISE PREAUTH PAGE:
  14. 14. PRE-AUTHORIZATION:  The hospital will submit the prescribed documents through this portal for the approval of a surgical procedure/medical management  On verification of the documents by the validator and the pre-auth approver (concerned specialist/doctors) put up in the scheme project office of United India Insurance Company at Kilpauk Chennai. The validator will check the non medical documents and the BSA (Balance sum assured) and gives the remarks. The pre-auth approver will go through the medical documents and approves the procedure or he/validator may rise queries, need more and denies as the case may be.  Based on the queries raised by the validator or approver the hospital must submit the required documents for further process.  The pre-auth grid page consists of 12 digit random generated pre-auth reference ID (Ref ID: 2H_186101065300), patient name, district, hospital name, pre-auth submission time, status of the pre- auth, procedure applied for, package cost including total aging (time taken for the processing of pre- auth)  Individual patient wise pre-auth will have the beneficiary demographic details, medical history, diagnosis, plan of management package selected with rate and provision to upload prescribed documents like pre-authorization form, investigations reports/films, clinical photos, eligibility documents (new smart card or old scheme card or xerox copy of ration card and VAO family income certificate less than 72,000 per annum) and remarks column CLAIMS CLAIMS INBOX
  15. 15. INDIVIDUAL PATIENT WISE CLAIMS CLAIMS :  The beneficiary will undergo approved surgical or medical management at the hospital following the preauth approval  The claims documents will be uploaded by the LO and DMO at the NWH following the discharge of patient  Since the scheme is entirely cashless, the patient need not to pay money for the treatment under this scheme  The claims grid page will have the similar details as of the preauth inbox  In the claims the hospital should submit/upload complete treatment details discharge summary and mandatory reports as per the protocol. Similarly the submitted claims will be processed by the claims validator and the approver available at the Project office  Following approval the claim money will be transferred electronically (e-payment) from the portal to the bank account number of the concerned hospitals  Entire process of claims submission to e-payment should be done within a period of 7 day E-PAYMENT:
  16. 16. DIAGNOSTIC SERVICES DIAGNOSTIC SERVICES  There are 23 stand alone diagnostic procedures are identified and approved in the scheme, so far 333 diagnostic centers are been empanelled which includes TNMSC centers.  The patient should be referred in a prescribed format from a government doctor along with the eligible documents are alone will be entertained for this procedures  Diagnostic services in the scheme is a claim only module so the document will be submitted for DC module exclusively enabled in the portal, the claim will be settled similarly as explained in the claims
  17. 17. SPECIALITY CATEGORIES SPECIALITY WISE PROCEDURES
  18. 18. BREAKUP OF PROCEDURES PRE-OP & POST-OP REQUIREMENTS  As we already mentioned the scheme covers 1016 medical and surgical procedures. It includes 33 specialities in addition to the stand alone diagnostic procedures and follow up procedures.  Break up – surgical 686 procedures, medical management 215, interventional radiology 36, diagnostic procedures 23, Govt. reserved procedures 56, follow up 113  The entire details of the procedure wise and speciality wise are available in this scheme portal.  Out of 1016 approved procedures, 56 procedures from general surgery, O&G, Ortho, ENT specialities are reserved to government hospitals alone in order to improve the performance, infrastructure facility in the public sector  For easy understandings to the empanelled Network hospitals the pre-operative and post operative requirements for processing of pre-auth and claims.
  19. 19.  LIST OF GOVERNMENT RESERVED PROCEDURES: I - E.N.T Slno EAR 1 MASTOIDECTOMY 2 STAPEDECTOMY – VEINGRAFT 3 TYMPANOPLASTY 4 FACIAL NERVE DECOMPRESSION THROAT 5 LARYNGO FISSURECTOMY 6 ADENOIDECTOMY - GROMET INSERTION NOSE 7 EXCISION OF BENIGN TUMOUR NOSE 8 ANGIOFIBROMA NOSE 9 ENDOSCOPIC DCR 10 ENDOSCOPIC SINUS SURGERY 11 BRONCHOSCOPY -FOREIGN BODY REMOVAL 12 FB CRICOPHARYNX ESOPHAGUS II - ORTHOPEDIC TRAUMA 13 SURGICAL CORRECTION OF LONGBONE FRACTURE 14 AMPUTATION SURGERY 15 SOFT TISSUE INJURY FRACTURE CORRECTION SURGERIES / PROCEDURES 16 BONE GRAFTING AS EXCLUSIVE PROCEDURE 17 OPEN REDUCTION & INTERNAL FIXATION OF FINGERS & TOES 18 REDUCTION OF COMPOUND FRACTURES & EXTERNAL FIXATION DISLOCATIONS 19 OPEN REDUCTION OF DISLOCATIONS – DEEP BONE AND JOINT SURGERY / PROCEDURES 20 AVASCULAR NECROSIS OF FEMORAL HEAD (CORE DECOMPRESSION) 21 SOFT TISSUE RECONSTRUCTION PROCEDURES FOR JOINTS/OSTEOTOMY POLY TRAUMA WOUND MANAGEMENT FOR COMPOUND FRACTURES 22 GRADE-I& II 23 GRADE-III OTHER SMALL BONE FRACTURES-K-WIRING (TO BE COVERED ALONG WITH OTHER INJURIES ONLY AND NOT AS EXCLUSIVE PROCEDURE) 24 SURGERY FOR PATELLA FRACTURE (TO BE COVERED ALONG WITH OTHER INJURIES ONLY AND NOT AS EXCLUSIVE PROCEDURE) 25 SMALL BONE FRACTURES-K-WIRING (TO BE COVERED ALONG WITH OTHER INJURIES ONLY AND NOT AS EXCLUSIVE PROCEDURE) III - GYNAECOLOGY AND OBSTETRICS SURGERY 26 RUPTURE UTERUS WITH TUBECTOMY
  20. 20. 27 ECLAMPSIA WITH COMPLICATIONS REQUIRING VENTILATORY SUPPORT GYNAECOLOGY 28 VAGINAL HYSTERECTOMY WITH PELVIC FLOOR REPAIR 29 CYSTOCELE ,RECTOCELE & PERINEORRAPHY 30 VAGINAL HYSTERECTOMY 31 ABDOMINAL HYSTRECTOMY FOR BENIGN CONDITIONS 32 DIAGNOSTIC HYSTERO- LAPROSCOPY IV - GENERAL SURGERY HEAD & NECK 33 BRANCHIAL CYST EXCISION 34 CYSTIC HYGROMA EXCISION-MINOR 35 REMOVAL OF SUBMANDIBULAR SALIVARY GLAND 36 EXCISION OF THYROGLOSSAL CYST FISTULA THYROID (NON MALIGNANT) 37 HEMITHYROIDECTOMY 38 ISTHMECTOMY 39 PARTIAL THYROIDECTOMY 40 RESECTION ENUCLEATION 41 SUBTOTAL THYROIDECTOMY 42 TOTAL THYROIDECTOMY BREAST 43 SIMPLE MASTECTOMY(NM) 44 MODIFIED RADICAL MASTECTOMY ABDOMEN – HERNIA 45 EPIGASTRIC HERNIA WITHOUT MESH 46 EPIGASTRIC HERNIA WITH MESH 47 UMBILICAL HERNIA WITHOUT MESH 48 UMBILICAL HERNIA WITH MESH 49 VENTRAL AND SCAR HERNIA WITHOUT MESH 50 VENTRAL AND SCAR HERNIA WITH MESH APPENDIX 51 LAP. APPENDICECTOMY STOMACH, DUODENUM & JEJUNUM 52 PARTIAL/SUBTOTAL GASTRECTOMY FOR ULCER SMALL INTESTINE 53 RESECTION & ANASTOMOSIS OF SMALL INTESTINE LARGE INTESTINE 54 TOTAL COLECTOMY 55 COLOSTOMY 56 COLOSTOMY CLOSURE
  21. 21. SMART CARD SMART CARDS:  More than 1.34 cores of family covered under this CMCHIS scheme, for the scheme members a new smart card being distributed for the purpose of identify the family members in the scheme, BSA (Balance sum assured), eligibility etc.,  The details of distribution of smart card taluk /district wise are available in the web page under smart card tab. The distribution details are updated at regular intervals. TALUK WISE SMART CARD DISTRIBUTION DETAILS:
  22. 22. MEMBER SEARCH: MEMBER SEARCH:  The basic benefit of the member search is to verify their members details and their coverage. Anybody can login and can get the information regarding treatment and balance insurance coverage for that policy year.  Following details can be verified by the members of the scheme by entering their 21 digit URN No given in the smart card or ration card No; Address, city, Village, District, URN NO, Ration card No, policy sum assured, total claimed amount and balance amount.  Once the smart card is distributed to all 1.34 crores of families , the member ID will be enable
  23. 23. HEALTH CAMP MANAGEMENT HEALTH CAMP MANAGEMENT:  There are two types of Health/screening camp are being conducted in this scheme – Individual and Mega camps.  Individual camp - All the empanelled hospitals should do a mandatory monthly camp as per the tender rules.  Mega camps are conducted by the district administration by involving more number of hospitals including empanelled government hospitals  In our scheme portal there is a separate module for entering the patient details referred from both the camps for the purpose of tracking the patient referred from the field to the treatment outcome at the network hospitals.  In addition to the above mentioned there is also facility to communicate the schedule of the mandatory camp to the network hospitals and the entire camp details are also being captured.

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