Claims Adjudication Manual - Ayushman Uttarakhand · 1. about ab pm-ja y 7kh*ryhuqphqwri,qgldlvfrp...
Transcript of Claims Adjudication Manual - Ayushman Uttarakhand · 1. about ab pm-ja y 7kh*ryhuqphqwri,qgldlvfrp...
Claims Adjudication
Manual | a
Claims Adjudication Manual
Ayushman Bharat
Pradhan Mantri Jan Arogya Yojana (PM-JAY)
National Health AUTHORITY
February 2019
Table of Contents
ACRONYMS ........................................................................................................................................................................ 5
1. ABOUT AB PM-JAY ..................................................................................................................................................... 6
2. PURPOSE OF MANUAL .............................................................................................................................................. 7
3. BASICS OF ADJUDICATION ...................................................................................................................................... 7
4. TARGET TURN- AROUND-TIME ................................................................................................................................ 9
5. ROLES & RESPONSIBILITIES ................................................................................................................................... 9
6. END TO END WORKFLOW......................................................................................................................................... 11
7. PROCESS FLOWS ....................................................................................................................................................... 12
7.1. Pre-authorization Process. .................................................................................................................................... 12
7.2. Claims Processing ................................................................................................................................................. 15
7.3. Review by Accounts Officer and Payment by SHA/IC ........................................................................................ 20
7.4. Reconsideration of Rejected Claim. ..................................................................................................................... 20
7.5. Claims Audit for Quality Check ............................................................................................................................. 21
8. COMPLICATED CASES .............................................................................................................................................. 21
8.1. Leave Against Medical Advice (Lama)/Discharge Against Medical Advice (DAMA) ........................................ 21
8.2. Mortality Case ........................................................................................................................................................ 21
8.3. Unspecified Surgical Cases .................................................................................................................................. 22
8.4. Portability Cases .................................................................................................................................................... 23
8.5. Enhancements and Partial Payments .................................................................................................................. 24
8.6. Unbundling of Procedures..................................................................................................................................... 24
8.7. Treatment Beyond Sum Insured/ Available Wallet .............................................................................................. 25
8.8. Payment in Case of Hybrid Model ........................................................................................................................ 25
ANNEXURE 1: EXCLUSIONS TO THE POLICY/SCHEME ............................................................................................ 26
ANNEXURE 2: template – OT NOTES, CLINICAL NOTES, DISCHARGE CARD AND CLINICAL PHOTO ........... 27
Claims Adjudication Manual | 3
Acronyms
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Claims Adjudication Manual | 5
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6 | Claims Adjudication Manual
2. Purpose of Man ual
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Claims Adjudication Manual | 7
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8 | Claims Adjudication Manual
4. Ta get Turn- Aro und-Time
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Claims Adjudication Manual | 9
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10 | Claims Adjudication Manual
6. End to En d Wor kflow
Pre-authorization Initiated
by MEDCO/PMAM
Response to query
Case Auto-approved for Case requiring manual
listed procedure approval from PPD
Raise Query
tat 6 hours
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patient discharged by PMAM
tat 15 days
Claim updated and claim
initiated by PMAM
Response to query
Claim processing by
CPD/Trust/ Insurance
Raise Query
tat 15 days
Rejected Approved
Accounts Officer
IC/ SHA Approval (if
mandatory)
Claim settlement
Claims Adjudication Manual | 11
7. Pr cess F lows
7.1. Pre-author ization Process
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Please refer to Approver’s Ma nual for detailed infor mation on the above:
https://w ww.pmjay.gov.in/site s/default/fil es/2018-12/Approvals %20_User_ Manual_v2.0.pdf
12 | Claims Adjudication Manual
Actions to be taken by PPD on a Pre-auth orization r equest (TA T: 6 Hours)
Surgical /
Medical Package Enhancement of
Medical Package
Auto Approval Without Auto
Approval
PPD’s bucket
Assigned to
Entitlement Check
Validate beneficiary details (name, age, sex
etc.) mentioned in the Pre-auth form against
the ones stored against PM-JAY id
Documents Review
PPD shall ensure:
- All mandatory documents are uploaded - Symptoms & diagnosis are in sync - Diagnostic reports conclude the diagnosis - Package requested is in sync with diagnosis
Investigation and Audit
If required, the case would be sent for
investigation
Assigned to
Another PPD/
Medical Committee
Approve/ Reject/
Query
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Claims Adjudication Manual | 13
7.1.2. D ocuments review
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14 | Claims Adjudication Manual
Investigation and A udit
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Claims Adjudication Manual | 15
F Cla im Proces ed by Clai ms Panel Doctor (CPD)
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16 | Claims Adjudication Manual
Actions to be taken on a claim by CEX & CPD:
Submitted Claim
CEX bucket
Claim Executive (CEX)
Non-Technical review:
- Confirm upload of mandatory documents - Confirm upload of all package specific
documents
- Match beneficiary’s bed side photo with
the one saved against PM-JAY id
CPD bucket
Claims Panel Doctor (CPD)
Technical review of documents
- Symptoms & diagnosis are in sync - Diagnostic reports conclude the diagnosis - Package requested is in sync with diagnosis - Post surgery reports confirm that
the booked surgery was performed
Investigation and Audit
If required, the case would be sent
for investigation
Assigned to
Assigned to Another CPD/
Medical Committee
Approve/ Reject/
Query
Claims Processing Timeline
Successful submission
Treatment of claim - 15 days
Time
Patient admitted Patient Claim
discharged successfully
for treatment
from hospital submitted
Time spent in claims and accounts
department - 15 days
Claim validated
Claim Payment
by CEX & CPD
Claims Adjudication Manual | 17
7.2.1. N on-Technic al Docume ts Review
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20 | Claims Adjudication Manual
7.5. Claims Au it for Quality Che ck
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Claims Adjudication Manual | 21
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24 | Claims Adjudication Manual
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Claims Adjudication Manual | 27