WELCOME AAROGYASRI HEALTH CARE TRUST

OPERATIONS WING

CASE PROCESSING

PRE-AUTHORISATION

CLAIMS

FOLLOW-UP CLAIMS

ENHANCEMENTS

ERRONEOUS CLAIMS

MISCELLANEOUS

Aarogyasri Mithras

RAMCO

Treating Doctor

Executives

Team Leaders

Panel/Trust

Doctors

• Positive Purposeful Productive Association • Clear Transparent Polite Exchange of Communication

Pre-auth Dept.

Net Work Hospital

WORK INTERFACE

P A T I E N T

WORK FLOW

NWH

Elective Cases Emergency Cases

Emergency Telephonic Approval

Patient Registration

Medical Consultation

Updating OP/IP Status

Outpatient

Consultation & prescription

Inpatient

Patient-on-bed

E-preauthorization

Preauth approval

Surgery/Therapy

Discharge

Follow-up Claims

• Beneficiaries approaches NWH from various sources • Aarogya Mithra examines the referral card / BPL card and facilitates the beneficiary to undergo Preliminary Diagnosis and basic tests. • Network Hospital, basing on the Diagnosis, admits and sends Preauthorization Request through E-Preauthorisation by RAMCO. • Pre-auth Executive(PEX) will verify homepage,WAP number, details of the Pt. and all other non-medical documents like Pre-auth forms, consent, counseling, DTRS forms, Health card/White card etc., and forward to the Panel doctor (Specialist) with remarks. • Panel doctor (Specialist) examines, verifies and approves if all the conditions/Documents are as per AHCT guidelines or kept pending for want of clarification on remarks from NWH. • After Panel doctor, The Trust doctor examines , verifies all documents and Approve / Pending / Reject the case. • After Trust approval the NWH extends Cashless Treatment and provides Cashless Surgery/Therapy.

PROCESS FLOW OF PREAUTHORIZATION

Receive the patient Verify the documents of the patients like health card/ration card/ beneficiary copy/Birth certificate/delivery certificate in case of child etc.

Facilitates the Patient for consultation with concern specialist and for admission. Facilitates NWH to send proper pre-authorization as follows. a) In patient Case registration and handovers the pt. to RAMCO b) Preauth updation by RAMCO of NWH Facilitates the approval and Treatment/Surgery

ROLE OF AAROGYA MITHRA

(Treating doctor/RAMCO/Aarogya mithra) Telephonic Intimation-Initiated

(Aarogya Mithra) Telephonic Intimation-Registered by Mithra

(RAMCO) In-Patient Case Registered

Telephonic Intimation for Medical/Surgical Emergency cases

Telephonic Intimation Initiated

Telephonic Intimation ID Cancelled

If IP registration not done with in 72hrs.

Emergency Telephonic Intimation Numbers :

1) 8333817471, 2) 8333817472 3) 8333817473, 4) 8333817475

Telephonic ID provided by Trust on NWH request

The Pre-auth executive(PEX) will verify Non technical document details of Preauthorization .

Facilitate the Emergency Telephonic approval cases by connecting the call conference to Trust doctors and enter the details of surgery/ treatment and other data of the Pt and NWH and provides telephonic intimation ID. (TID)

Monitoring on regular basis for clearance of pre-authorisations in TAT( Turn Around Time) i.e. in 12 hours

ACTIVITY OF PREAUTH EXECUTIVE

After detailed examination and verification of the submitted technical documents, the Panel doctor (Specialist) approves and forward the case to the Trust Doctor for further process.

If the Documentary evidence is insufficient doctor will keep the case pending for updating remarks.

If the pending updated by NWH is not satisfactory as per the AHCT guidelines the case will be rejected.

Aarogya mithra / Executives quickly follow up the case with RAMCO of the NWH to update the Case.

PREAUTH DOCTORS (PANEL & TRUST)

W A P Card (White Andhra Pradesh Card) A A P Card (Annapoorna Andhra Pradesh Card) Y A P Card (Anthyodaya Anna Yojana Card) Health Card (Rajiv Aarogyasri Bheema Health Card) Journalist Card (JPAP) T A P Card (Temporary Andhra Pradesh Card) RAP Card (Rachhabanda Andhra Pradesh Card) CMCO letter

Pediatric Cases Beneficiary Copy / Birth certificate / Delivery certificate / Self declaration by parents.

ELIGIBILITY CRIETERIA

Health Card (Rajiv Aarogyasri Bheema Health Card)

District name

is mentioned

in the

Aarogyasri

health card

District is

also indicated

using color

code

WAP0483003B0052 District op Number (B – 2nd shop in that Mandal)

Mandal Cons. code

What exactly WAP number says?

WAP (WHITE ANDHRA PRADESH) CARD

Y A P Card (Anthyodaya Anna Yojana Card)

Barcode

A A P Card (Annapoorna Andhra Pradesh Card)

Barcode

Chief Minister Camp Office Referral letter (CMCO Referral Card)

Rachhabanda Andhra Pradesh Card

Beneficiary photo

BENEFICIARY COPY FOR TAP CARD (ELECTIVE CASES)

Temporary Andhra Pradesh Card

TAP01C401027105 District op Number

Mandal Cons. code

What exactly TAP number says?

Points to remember: No Photograph of the Beneficiaries No Barcode Reader

Journalist (Working / Retired) Scheme Under CMRF

Journalist

Card no.

Barcode

© Star Health and Allied Insurance Co. Ltd.

THE PATIENT SHOULD BE ALLOWED TO SUBMIT ANY OF THE 17 PHOTO IDENTITY PROOF LISTED BELOW ALONG WITH TAP/RAP

CARD FOR ANY EMERGENCY CASE

• 1.Election photo Id card

• 2.Job card issued under NREGP

• 3.Pension document

• 4.Pattadar Pass book

• 5. House site pattedar

• 6. SC/ST/BC Certificate

• 7. Certificate of Physical Handicap

• 8. Registration document containing the photograph

• 9. Student identity card issued by recognized educational Institution

• 10. Driving license

• 11.Pass book with photograph issued by public sector bank/post office

• 12. Freedom fighter ID card

• 13. ID card issued to BIDI workers by Min of Labour

• 14. PAN Card

• 15. ATM card with photograph

• 16. Passport

• 17. Aadhar Card

For Pediatric Emergency Case (Bedside Photo of Mother/Father

with New Born Baby + Birth Certificate issued by the Hospital)

Father’s

Health

card

On

bed

photo

On bed

Photo

with

parents

S.No Anomaly in cards Nature of

Treatment Requirement for benefit

1 No Rajiv Aarogyasri Health card - BPL card

2

No name but photo available in the

White card/health card and photograph

matches the patient

- Patient self declaration is

enough

3 Name is there but photo is not available

on White card/Health card -

Any photo ID card( Driving

license, College/ School ID

certificate from tahsildar

along with photograph etc.,)

to correlate the patient name

and photograph

4 Xerox copy of the card - Check the card details online

5 Loss of card due to a natural disaster - Rice coupons- WAP number

Check card details online

ANOMALY IN CARDS

Fake-White Andhra Pradesh card (WAP-Card)

S.No. should start with 2

Photos are in different directions

NET WORK HOSPITAL PREAUTHORIZATION DEPT

Pending Lack of proper documentation. Documentary evidence submitted insufficient to support the diagnosis and treatment plan.

Rejections Inappropriate treatment plan. / Non submission of required documents

Cancellations With out updating the pending remarks applying cancellation and raising the second Preauth.

Improper cancellation documents

Preauthorization Issues

Guidelines for Pediatrics age group patient

NWH has to provide cashless treatment to any patient admitted under pediatric

age can be treated under Aarogyasri without his/her name in any card

like…WAP/RAP/TAP/ etc… on fulfillment any of following documents.

Date of birth certificate or

Letter issued by tahsildar or

Delivery certificate or

Beneficiary certificate issued by District Collector or

Declaration by the parent

Due to non availability of laparoscopic surgeons the Trust has allowed to Govt.

hospitals to perform by open method and the package for open procedure is as per

the annexure.

For other NWH if they are unable to continue to perform lap. Technique,

same open package amount will be approved as per the explanation given by

the NWH.

Category Code Name of the Procedure

Package amount

Proposed package amount.

General Surgery S1.3.2.1 Lap. Appendicectomy

18000 17500

Pediatric Surgeries

S8.8.7 Lap. Appendicectomy

25000 17500

Surgical Gastroenterology

S6.7.4 Lap. Cholecystectomy

30000 17500

Gynecology & Obstetrics

S4.2.1 LAVH 20000 17500

ENHANCEMENT CASES

Enhancement of Package may be considered in certain cases where hospitals

have to attend :-

1) Associated diseases not packaged under Aarogyasri scheme.

2) For the same patient extended surgeries in certain situations.

3) Extended stay on account of unrelated complications.

In order to facilitate the hospitals to continue to provide cashless treatment

under the scheme.

ENHANCEMENT CASES GUIDELINES

CASES ELIGIBLE FOR CONSIDERATION OF ENHANCEMENT MEDICAL TECHNICAL COMMITTEE COMPRISING OF SENIOR OFFICIALS WILL PROCESS THE FLOW 1. HIV, HbsAg or HCV positive cases – 5000/- for additional expenditure 2. For Additional surgical procedure/Treatment, which is not covered under Aarogyasri scheme in

addition to the Treatment approved under the scheme . 3. Extension of Procedure due to underlying (Anatomical, Pathological etc.,) variances . 4. Complications totally unrelated to the surgical procedure and due to underlying associated conditions such as a. Diabetes b. Hypertension c. Immunosuppressive status etc . 5. Medical/Surgical Complications for which packages are available but totally unrelated to the approved Surgery/Therapy for which the hospital cannot be empanelled due to infrastructure requirements. (In all such

cases enhancement amount shall be equal to the approved package amount under the scheme). 6. For associated injuries in poly-trauma for which no package is available in the scheme . 7. Complications in cases of Medical / Conservative Management for which packages are not available under the scheme leading to extended hospital stay . 8. Approval of Enhancement shall be with in the package limit of Two Lakhs per Family per Year.

ENHANCEMENT CASES FOR REJECTION

a) Subsequent requests for the enhancement after being approved once.

b) Early submission of request before indicative period

c) Submission of request after discharge.

d) Mere presumption of case may get into complications in advance due to

high risk will not be considered

e) Common post operative complications directly attributed to primary

ailment for which pre-authorization was obtained. The hospital shall

extend cash less treatment to this complications under the same package.

The hospital shall extend the cashless treatment and services to the

Aarogyasri patients under the approved package irrespective of the status of

the enhancement.

When ever there is wrong uploading of documents by NWH like patient on bed

home page photo, WAP card Number, Gender, Age, OT details etc…

The NWH is permitted to raise the request for change of wrong document to clear

the claim.

In case of preauthorization they can cancel the Preauth and can raise fresh

Preauth with correct documents

Change Management System (CMS)

CHANGE MANAGEMENT SYSTEM (CMS)

CREATING REQUEST FOR CMS