ECHS – Revised Procedure for Procession of Waiver and Sanctions: Online Claims

ECHS – Revised Procedure for Procession of Waiver and Sanctions: Online Claims

BI49778/AG/ECHS/Claim/Policy 

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(All Regional Centres ECHS)

REVISED PROCEDURE FOR PROCESSING OF WAIVER AND SANCTIONS : ONLlNE CLAIMS

1. Refs:-
(a) Our letter No Bl49779/OutsourcingIAG/ECHS dt 11 Jun 14.
(b) Our letter No BI49770/AGIECHS dt 09 Jun 15.
(c) Our letter No B/49779-Outsourcing/AG/ECHS dt 24 Jul 17.
(d) Our letter No B/49779-Outsourcing/AG/ECHS dt 22 Aug 17.

3. The existing timeline for processing of online claims is as under:-

Ser No	Details	Timeline
Empanelled Hospital Claims
(a)	Admission Intimation	Within 24 Hrs-from time ADMISSION
(b)	Online Submission of Claim	Within 04 Days from Date of Discharge
(c)	Submission of Hard Copies of Claim	Within 30 Days from Date of Discharge
(d)	Query & Need more Info Reply	Within 30 Days of Query/NMI Date
Individual Reimbursement Claims
(e)	Admission Intimation (EIR)	Within 48 hrs from time of admission
	Submission of Hard Copy	Within 30 Days from Date of Discharge

 

 

 

 

 

Ser No	Type of Activity	Procedure in Vogue (Timeline)	Revised Procedure wef 01 Oct 17	Remarks (Including Disposal of old cases)
EMPANELLED HOSPITAL CLAIMS
1	intimation of Admission to  BPA	Within 24 Hrs-from time of admission	Within 48 Hrs from time of admission (Revised Timeline)	One time waiver is accorded for all old cases till 30 Sep 17
			Upto 30 days – Waiver by Dir RC on justification
			Beyond 30 days – No (NO) waiver will be accorded
2	Emergency Referral (ER) in Emergency Cases	Within 24 Hrs from time of admission	Within 48 Hrs from time of admission (Revised Timeline)	One time waiver is accorded for all old cases till 30 Sep 17
			Waiver by OIC Polyclinic upto 07 days from the date of hospitalization I date of discharge whichever earlier (valid justification needed)
			Upto 30 days – Waiver by Dir RC on justification
			Beyond 30 days – No (NO) waiver will be accorded
3	Online Claim (IPIOP) Submission in BPA portal	Within 04 working days from date of discharge	Within 07 working days from date of discharge (Revised Timeline)	One time waiver is
			Upto 60 days – Waiver by Dir RC on justification	accorded for all old
			Beyond 60 days – No (NO) waiver will be accorded	cases till 30 Sep 17
4	Submission of Hard Copy of Claim (IP/OP) to Regional Centre	Within 30 days from    date of discharge	Within 60 days from date of discharge (Revised Timeline)	One time waiver is accorded for all old cases till 30 Sep 17
			Wef 61- 90 days – Waiver by Dir RC on justification
			Beyond 90 days  No NO waiver will be accorded
5	Need More Information (NW)	Within 30 days from date of NMI	The prevailing procedure of granting waiver at various intervals shall be discontinued wef 01 Oct 17 vide letter No B/49779-Outsourcing/AG/ECHS dt 24 Jul 17 as amended vide our letter No B/49779-Outsourcing/AG/ECHS dt 22 Aug 17 and also a comprehensive guidelines for disposal of NMI cases within stipulated time frame has been issued	After 180 days, claim to be settled based on available documents with deductions (if needed) or rejected depending upon the status of the claim
INDIVIDUAL REIMBURSEMENT CLAIMS (NON EMPANELLED HOSPITALS)
6	Intimation of Admission/ Emergency Information Report (EIR) to Polyclinic by ECHS beneficiary/ NOK in case of Emergency admission in Non Empanelled Hospitals	Within 48 Hrs from time of admission	Within 48 Hrs from time of admission	OIC Polyclinic and Dir RC to ensure that no reimbursement claim remains pending in the system for NMI disposal beyond 180 days
			Waiver by Dir RC, if intimation recd within hospitalization  period
			If delayed beyond hospitalization period upto 90 days from date of discharge, application to be processed by Dir RC with justification to Central Org ECHS, as per format fwd vide our letter No 13/49770/AG/ECHS dt 21 Nov 16
7	Submission of Hard Copy of claim to Polyclinic	Within 30 days from date of discharge	Within 90 days from date of discharge (Revised Timeline)
			Wef 91-180 days from date of discharge, waiver to be given by Dir RC
			Beyond 180 days from date of discharge, waiver to be given by Central Org ECHS
8	Need More information (NMI)	Within 30 days from date of NMI	There is no stage wise time restriction imposed on the individual reimbursement claims and a comprehensive guidelines for processing of Individual Reimbursement Claims has been issued vide letter No B/49779-Outsourcing/AG/ECHS dt 24 Jul 17 GOVT HOSPITALS
9	Treatment in Govt Hospitals	ECHS beneficiary may avail treatment without obtaining referral from polyclinics. However, referral will only be required for the specified treatment such as Organ Treatment Surgery, Knee and Hip Joint Replacement, Cancer Treatment, Neurosurgery and Cardiac Surgery vide Gel, MoD letter No 22D(09)/2013/US(WE)/ D(Res) dt 26 Jul 16	Intimation of Admission within 48 Hrs by ECHS beneficiary / NOK to parent / nearest Polyclinic
			Within 90 days from date of discharge – Hard copy of claim by ECHS beneficiary / dependent should be submitted at Polyclinic
			Upto 180 days – Waiver by Dir RC on justification for delay in admission intimation and referral both
			Beyond 180 days from date of discharge, waiver to be given by Central Org ECHS for delay in admission intimation and referral both
MISC CONCURRENCE CASES
10	Misc concurrence required by BPA to process the claims, as follows (a) Discrepancy in overlapping of admission and discharge dates (b) Repeated admission for same ailment within short duration (c) On table procedure/additional procedure done	No policy exists	Waiver to be given  by Central Org  ECHS. Cases to be examined in detail by RC and fwd with due justification and recommendation of Dir RC as per format fwd v de our letter No 13/497713/AG/ECHS/ Claim/Policy dt 03 Nov 16
SANCTIONS
11	Approval on Appx ‘A’ of Cardiologist of Comd 1 Zonal Hospital for:- (a) Unlisted procedures. (b) Cardiac implants (listed 1 unlisted). (c) More than 02 DES and 01 Base Metal Stent (PTCA)	Approval given by Cardiologist after physical checking of all relevant Documents	Status  quo  to  be  maintained.  However, PC/RC may consider feasibility to obtain online approval to save time and subsequently hard copy to be sent by post	In case of emergency, no approval need to be taken
12	Organ Transplant (Liver & Lungs)	Approval given by MD ECHS	Status quo to be maintained
13	Approval on Appx ‘A’ for Unlisted Procedure/Test/Implants at ECHS Empanelled Hospital	Approval given by SEMO on revised Appx ‘A’ as per our letter No B1497781 AG/ECHS/PA/Ruling dt 03 Feb 17	Status quo to be maintained
14	Extended Hospital Admission on Appx ‘A’	13-30 days by OIC Polyclinic	Status quo to be maintained
15	Extended Hospital Admission on Appx ‘B’	31-60 days by Dir RC	Status quo to be maintained
16	Extended Hospital Admission on Appx ‘C’	61-120 days by MD ECHS	Status quo to be maintained

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