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MJPJAY & PMJAY.pptx
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- 2. Eligibility of MJPJAY& PMJAY All patients of Maharashtra those who have Yellow & Orange Ration Card are the beneficiaries of MJPJAY All patients other than Maharashtra state having Yellow & Orange ration card are the beneficiaries under PMJAY. Those who have CAPF cards will be also beneficiary under PMJAY. White ration card holders are not eligible for MJPJAY & PMJAY.
- 3. Necessary Documents forBeneficiary Enrollment Original Aadhar Card (Xerox is not acceptable) Ration Card- Original (Yellow/Orange) Bank Passbook- (Nationalized bank preferred)- Required in case of Hospital needs to refund the patient. Ayushyman Bharat Card/ Golden card for PMJAY Beneficiaries.
- 4. Difference Between ABHAcard & Ayushman Bharat Card Ayushman Bharat Card Purpose- Cashless healthcare to the beneficiaries. Eligibility- Identified by Socio Economic & Caste Census (SECC) Benefits- Free critical healthcare treatment Coverage- Up to Rs.5 Lakh, per family per year. Income Group- Low- Income group Enrollment- Mandatory for the beneficiaries ABHA card (Health ID) Purpose- Access and share Health Records digitally. Eligibility- Available to all Citizens Benefits- Creates unique identity within the healthcare. Coverage- Unlimited storage of Medical report Income Group- Everyone included Enrollment- Voluntary
- 5. Difference Between ABHAcard & Ayushman Bharat Card Ayushman Bharat Card ABHA card (Health ID)
- 6. Pterygium Pterygium- InPterygium surgery MJPJAY package covers only Conjunctival Autograft, if patient wants with Glue then we can convert him/her in cash package. Pre Op Requirement- Clinical Photograph and clinical notes Post Op Requirement- Clinical Notes, Post procedure evidence of Surgery. Package- Rs.7000/-
- 7. Retina In Retina surgeryMJPJAY has multiple surgical procedures- 1. Vitrectomy- 6000/- 2. Vitrectomy+ Membrane Peeling+ Endolaser- Rs.25000/- 3. Vitrectomy+ Membrane Peeling+ Endolaser+ Silicon Oil Or Gas- Rs.30000/- Patient who has RD- Retina Detachment, TRD- Total Retina Detachment, Macular Hole, Vitreous Hemorrhage etc can be operated under Vitrectomy package by adding other procedures. Vitrectomy can be added with additional procedures Like VR + Buckling –Rs.45000/- Silicon Oil Removal can also be done in MJPJAY, Rs.-6000/- Buckle Removal is also covered under MJPJAY, Rs.5000/- If patient did 1st surgery in MJPJAY and been advised for Re-RD, in order to get Re-RD surgery in MJPJAY patient should wait for 1 year.
- 8. Retina Monthly AntiVEGF injections can be done in MJPJAY, Rs.7000/- Per month 1 injection for one eye and total 6 injections per eye in a year can be given. PRP laser can be done under MJPJAY- Photocoagulation For Diabetic Retinopathy Per Sitting- only 2 sitting per eye. Rs.1500 per sitting Barrage laser is not included in MJPJAY.
- 9. Pediatric Cataract Pediatriccataract- Rs.15000/- Age limit for Pediatric cataract is 14 years max. In this Package of Pediatric Cataract Phaco procedure need to do. Basic IOL of Foldable/Non Foldable can be implanted.
- 10. Squint Under MJPJAYSquint can be operated with below packages Rectus Muscle Surgery Single- Rs.6000/- Rectus Muscle Surgery Two/Three- 12000/- Oblique Muscle- 6000/- above packages can be added together as per patient’s requirement.
- 11. Important Notes AllPre Operative investigation/Diagnostics are covered under MJPJAY Path Lab services whether in house or outsourced, patient will not pay so Hospital need to arrange this facility on their own. Anesthetic backup charges are already included in the package itself we can not charge from patients. Post Operative surgical medicines are also covered in package. Ideally 1 follow-up we can provide as free, otherwise once patient get discharge, he is no longer MJPJAY Beneficiary. Patient on their own want to go for Private then he/she should sign the consent. (Will share format separately) MJPJAY can not be combined with cash/upgradation facility, either MJPJAY or private.
- 12. Important Notes If2 surgical packages clubbed together then we get 100% of 1st package and 50% of 2nd package. For Eg (1)- Vitrectomy+ Buckling, where Vitrectomy with other procedures is Rs.30000 and Buckling package is Rs.15000/- by combining these 2 surgical packages we will get 37500/- at the time of claim settlement. Here 1st package is VR so will get 100% which is Rs.30000/- and 2nd package is Buckling so will get 50% of 15000 which is 7500/- so total will be Rs.37500/- For Eg (2)- For Squint surgery Rectus Muscle surgery two/Three muscles + Oblique Muscle- 6000, here also will get 100% of Rectus muscle Rs.12000/- and 50% of Oblique Muscle Rs.3000/- total Rs.15000/- Note- While adding combined surgical packages always add higher package procedure first and then alternate package for second.
- 13. 13 BENEFICIARY REGISTRATION DIAGNOSIS & ADMISSION BENEFICIARY MEDICALCO-ORDINATOR Hospital Coordinator registers patient as in-patient Hospital Coordinator initiates Pre- Authorization MEDICAL CO-ORDINATOR Submit for Pre- authorization approval PREAUTH DOCTOR Preauth Panel Doctor provides pre- authorization approval/reject/ pending CLAIM EXECUTIVE TREATMENT, DISCHARGE BENEFICIARY MEDICAL CO- ORDINATOR* Surgery/ Discharge Details updated, and Claim request submitted by Hospital Coordinator CLAIMS MANAGEMENT Claim Forwarde d Case no. generated CLAIM DOCTOR PREAUTH PROCESSING ACCOUNTS OFFICER CLAIMS MANAGEMENT Claim Forwarded NHA Approve/ Reject/Quer y the submitted claims BANK Payment file is sent to bank Response file with transaction details is sent to NHA Ayushman ID Processing through Implementation support agency (s) Transactions Management System (TMS) Claims Process Flow
- 14. Prepared By Asif Makandar, CenterHead, Tararani Branch THANK YOU