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RSBY Revised Process Guidelines

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Document version and revision details

Sr. No.

Document version

Submission date

Reviewer Revision by Sign off by Date of sign off

Comments / remarks

1. Version 1.0 9th May 2014 Draft approved in-principle by Sub-groups

9th May 2014 Document will undergo continuous revisions over time for changes in policy/ field inputs

2. Version 2.0 13th May 2014 Approved at the Empowered Committee Meeting

15th May 2014

Document will undergo continuous revisions over time for changes in policy/ field inputs

3. Version 3.0 On-going


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Table of contents

S. No. Section Page number

1 Introduction …………………………………………………………. 1

2 Data preparation and pre-enrolment …………………………………………………………. 4

3 Enrolment …………………………………………………………. 19

4 Smart card and key management system …………………………………………………………. 35

5 Wellness check and payment of premium …………………………………………………………. 48

6 Hospital management …………………………………………………………. 60

7 Claim management …………………………………………………………. 75

8 Public grievance management …………………………………………………………. 84

9 Kiosk management …………………………………………………………. 106

10 MIS for RSBY …………………………………………………………. 122

11 Third party Audit of RSBY Scheme …………………………………………………………. 132

11 Annexures …………………………………………………………. 140


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Introduction

Social security and healthcare for all has been the motto of Government of India, and it has taken various steps in this regard.

One of the important policy milestones is the Unorganized Workers Social Security Act (2008) enacted by the Central Government to provide for the

social security and welfare of the unorganized workers. This act recommends that the central government provide social security schemes to mitigate

risks due to disability, health shocks, maternity, and old age, which all unorganized workers get exposed to, and are likely to suffer from. A number of

Central schemes are in operation and have provided protection to the beneficiaries from the unorganized worker segment. Additionally, a large number of

labour welfare funds set up by both central and state governments on non-contributory basis provide social security as well as financial assistance in some

cases to the unorganized workers in certain occupations.

One such policy initiatives in the health insurance space is RSBY that was launched in early 2008. RSBY was initially designed to target only the Below

Poverty Line (BPL) households, but has recently been expanded to cover a number of non-BPL categories of informal sector workers, including street

vendors, domestic workers, beedi workers, building and construction workers, and most importantly the workers who have worked for more than 15 days

under MGNREGS. Government of India and the State Governments are co-financing the premium cost for enrolled beneficiaries. Till date, more than 32

million eligible households are covered by RSBY. The program has the target to cover 70 million households by the end of the Twelfth Five Year Plan

(2012-17). Its service delivery model – demand financing, freedom of choice among accredited government and private hospitals, and cashless service

reimbursable to provider on a pre-determined package price basis, could become a strong pillar for the universal health care system laid down by

Government of India.

The scheme has faced various challenges in the implementation at the field level, and lack of complete and accurate information/data visibility on RSBY

services has been observed.

To address these challenges and to incorporate learnings of last 6 years, Ministry of Labour and Employment (MoLE) has decided for a major revamp of

complete system. These guidelines are first step in this direction. These guidelines have been prepared in consultation with sub-groups formed at Ministry

of Labour and Employment, Government of India, comprising of MoLE officers, State RSBY SNA teams, GIZ, and consulting partner support provided by

the World Bank.

The guideline document is a live document and needs to be re-visited / edited periodically based on learnings from field operations, policy changes

and technology modifications. The guideline highlights the current processes and modifications to these processes based on discussions with the sub-

groups at MoLE. The suggested changes shall be implemented by NIC in the stipulated time mentioned by MoLE to smoothen the existing RSBY phase.

The revised process guidelines for phase II for RSBY have been prepared for 8 sub-processes as depicted in the diagram below:


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Figure 1: RSBY Sub-processes


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Each sub-process has been assigned a process code and process objective, along with other placeholders within the guidelines template defined for every

sub-process. The placeholders that have been used in the template are depicted in Figure 2 below. The template captures the existing activities in RSBY,

and provides the revised set of activities, which will be taken up for implementation in the proposed phase II of revamped RSBY. The content in the

following sections of this document is subject to changes / modifications based on field experience, changes in the policy environment, and inputs from

various stakeholders and updates to the technology systems/applications.

Figure 2: Process template placeholders


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Pro

ce

ss

Co

de

I –DPENR Process Name

Data Preparation and pre-enrolment

Process Objective Current Status 1. Collection of beneficiary data from departments, deduplication of

data and creation of enrolment list for RSBY 2. Ensuring accuracy and consistency of data collected, both from a

structural and template perspective

1. Guidelines on 11 eligible beneficiary categories being used to solicit data from departments in the state

2. Different data formats (hard copy lists/excel/MS access/PDF) being used by departments to hand over pre-enrolment data to State Nodal Agencies (SNA’s). The formats vary across states and departments. It is expected that in future also, departments would continue to hand over data in their own format.

3. Data Collection template and enrolment/validation software is being changed to add attributes, such as NPR/Aadhaar number, which will make it easier to de-duplicate the data

Key Stakeholders Key Performance Indices (KPIs) 1. MoLE 2. State Departments responsible for pre-enrolment data collection

across 11 eligible categories Rural Development Department: BPL, NREGS (>15 days) and IGNOAPS Urban Local Bodies: BPL (U), Domestic worker, Rag pickers, sanitation workers and Rickshaw pullers Labor Welfare Commissioner: Beedi Workers State Board for Building and other construction workers: Construction worker State Transport department: Taxi/Auto drivers

Ministry of Mines/State department of Mines: Mine Workers Railways: porters Ministry of textiles. for textile worker data ( for using RSBY

Measures1: MoLE, SNA, Departments (relevant reports to be available, depending on role) 1. Data collected and processed from different department

Filters: User Category (Departments, SNA), Beneficiary category, Geography (State, District, Block, Village, Town, City (VTC), Processing status

2. Number of beneficiaries under multiple categories Filters: Geography

Key performance indicator2: (relevant KPI’s to be measured, depending on role) 1. Quality of deduplication as per audit report 2. Accuracy & completion of data shared by departments with SNA as per audit

report. (Accuracy to be measured as % of records which are de-duplicated at

1 All measures to be available as a report on a web portal in real-time/near-real-time. The data should be available in a warehouse, such that any extraction is possible to create ad-hoc reports

2 MIS on all KPIs to be available on a web portal in real-time/near-real-time, with authorised access


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platform) DFS – LIC data of AABY

3. SNA

source, and which follow data structure and template) 3. Total number and % of invalid records identified. Invalid records are those

with: - Missing mandatory information - Incorrect structure - Interchanged data, based on location (block, etc.)

4. Total number of records validated, de-duplicated and uploaded on MoLE servers for URN generation

5. Average time3 taken by MoLE to generate URN’s for all records after receipt of clean and de-duplicated pre-enrolment data from SNA’s

6. Average time taken by MoLE to hand over pre-enrolment data (URN generated) to Insurance company (IC)

7. Expected wait time to generate URN number for a reference data-set (for a district) when it is uploaded by the SNA - This will be computed and published every day based on current records

awaiting URN generation 8. Time taken by IC to acknowledge the validity of data received by MoLE

- This would be computed based on time difference between MoLE sending data, and IC notifying validity in the proposed web application

Current Challenges Summary of key suggestions 1. Pre-enrolment data shared by state departments in multiple

formats and data structures 2. Guidelines for validation /background check at field level of pre-

enrolment data not always followed by SNA 3. Lack of standard and practical guidelines and automated process

for de-duplication 4. In some states, data preparation for enrolment always starts

afresh and the data prepared for the previous year is not used, resulting in duplication of efforts. (Fresh pre-enrolment data uploaded by SNA does not include URN generated in the prior cycle)

5. Category prioritization guidelines for beneficiaries is not defined 6. Insurance company (IC) sometimes not provided with pre-

1. Standard template and data-structure to be used by departments for sharing data with SNA’s (eventually to do this using proposed web application). The proposed format is MS Access. (.mdb files)

2. Validation and deduplication of pre-enrolment data during entry by SNA’s (or eventually departments) in the proposed web application

3. Guidelines on prioritization of categories of beneficiaries (Annexure 1.1) to be defined and followed at the de-duplication stage for creating pre-enrolment data with URN

4. Standard deduplication and validation techniques to be followed by all departments and SNA’s (Annexure 1.2)

5. MoLE to provide URN generated pre-enrolment data to IC, 15 days prior to commencement of enrolment process, SNA should ensure to make available data to MoLE well in advance, taking into consideration expected waiting time

3 Average time to be calculated on the basis of time stamp associated with the activity available in data base


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enrolment data (with URN generated) in a timely manner by MoLE

7. Insurance company (IC) does not acknowledge the validity of data received by MoLE

indicated by MoLE 6. Robust process and system to be defined to check whether beneficiary

already has an RSBY card at the time of pre-enrolment. Departments to be encouraged to use a tablet/mobile based application for this purpose

7. Prior URN to be used at the time of pre-enrolment data preparation 8. Align the master data of geography (district, block) with that of census

Pre-requisites for the pre-enrolment and data preparation process 1. Availability of data capture templates (Annexure 1.3)with the state departments (till such time they start using the proposed web application) 2. Access of the proposed web application to SNA’s and MoLE users. (and eventually to departments) 3. Mandatory capture of atleast 1 key field for de-duplication (NPR number / Aadhaar number / Mobile number / NREGS ID / BPL card number) 4. On-boarding and training of MoLE technical team, SNA officials and state department officials on the pre-enrolment process.

Inputs to the revised process Output from the revised process 1. Pre-enrolment data from state departments 1. Pre-enrolment URN generated data for enrolment process

Processes and Responsibilities:

Sr. No

Current Process Responsibility Proposed Process Corresponding Responsibilities

Remarks

1 Preparation of data of eligible beneficiaries

1.1 Respective departments to collect pre-enrollment data

Respective state departments

1. Robust check at the time of pre-enrolment by State departments to ensure that the beneficiary does not have an RSBY card already. (can be done at the time of data collection by state department for respective scheme/program)

2. The format and template for capture of pre-enrolment data would be standard in the web application. The data capture

Respective state departments

1. In order to empower the departments for deduplication check at the time of pre-enrolment, electronic tools should be made available, through which they may search from the list of existing RSBY beneficiaries.

2. List of fields to be captured in the form:

S.No., Name of Beneficiary*, Father’s/Husband’s name, Date of birth / Age*, Gender*, Address*, VTC*


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Sr. No


Remarks

template has been defined in Annexure 1.3 of the guidelines

(Village/Town/City), District*, State*, Pin-code, Caste Category* (SC/ST/OBC/General), BPL category (out of 11)*, Number of dependents to be covered*, Local language, minority status, Mobile number*, Aadhaar number, NPR number, NREGS Job Card number, BPL Card Number, Ration Card number, Category Identifier number (for any of the 11 categories), Existing RSBY Card Number, Flag to indicate whether any family member has an RSBY card* (Y/N). Demographic of all family members/dependents to be covered.

The fields marked * are mandatory fields.

The final list of data fields should be as per the latest “RSBY Data Format” as per Annexure 1.3 of this document

3. The location/geographic data to be referred should be the latest census data

4. For future reporting on RSBY beneficiaries for political constituencies mapping the same to census data of villages/towns in the constituency can be done.


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Sr. No


Remarks

1.2 Previous year/cycle data not being used by SNA’s for fresh pre-enrolment resulting into duplication of efforts and potential duplication of beneficiary records

SNA Pre-enrolment data of previous year from MoLE to be used at the time of data validation and de-duplication.

SNA 1. At the time of data deduplication, the pre-enrolments records from previous year (with URN) should also be searched for.

2. Web-application for data collation, validation and de-duplication is proposed to be developed by NIC.

1.3 1. Merging the data received from various departments,

2. Deduplication of data by SNA

3. Transfer of final list to EDVASP software for format validation

SNA (The same is sometimes outsourced to an external agency or data management operators).

1. Merging of data received from various state departments should happen automatically in the proposed web-based system.

2. The system should prompt for invalid (format/structure) and duplicate records, which can be acted upon by an SNA official for processing the list.

SNA 1. The de-duplication would be a combination of automated duplicate alerts by the system (based on identifiers and demographic information) and simple manual confirmation to select appropriate records.

1.4 De-duplication of data being done

1. manually by SNA officials

2. not done at all

3. through locally developed application

SNA De-duplication of data, to be done through proposed web application using common identifiers like NPR number/ Aadhaar number/NREGS ID/ BPL card number/Mobile Number and other demographic parameters like name, fathers’ name, etc.

SNA 1. For de-duplication SNA to follow guideline provided by MoLE. For details refer Annexure 1.2

2. The de-duplication process should be allowed in an offline mode also, even though the prompting process will be done in a connected mode.

3. In case of duplicate records identified at MoLE level, the notification would go from MoLE to


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Sr. No


Remarks

the states.

1.5 1. Preference of category is being selected manually by SNA at the time of processing of pre-enrolment data received from respective state departments

SNA The rule for selection of appropriate category should be selected at the time of de-duplication. The system should prompt for selection of high priority category at the time of de-duplication.

SNA 1. Selection of category (based on prioritization guidelines) should happen in tandem with the de-duplication check.

2. This is not being done currently and needs to be incorporated in the guideline. Detailed rules of category prioritization have been provided in Annexure 1.1

2 Making pre-enrolment data available to MoLE

2.1 Validate data for format correctness using the EDVASP software provided by MoLE

SNA 1. The data is automatically validated at the time of first entry into the proposed web application. The validation is built into the web application.

2. A notification would be prompted by the web application on the number or records requested, number of records accepted/loaded, and number of records rejected.

3. Any invalid records would be sent back to the state departments

SNA 1. This would be possible once the proposed web application is rolled out. (Phase II). The SNA user will submit the pre-enrolment data on the web application, which will then be available to MoLE.

2. The user will be allowed to search the data by multiple demographic /geographic parameters.

3. In the database table, the code/reason for rejection would also be available. This may be indicated in summary at the


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Sr. No


Remarks

time of upload request.

2.2 SNA uses an FTP portal to upload all data in an MS Access file (.mdb) for MoLE consumption.

SNA Once the data is validated, de-duplicated and confirmed at the SNA level in the previous process, the data would be available to MoLE user on the web application for URN generation.

SNA This feature would be available once the proposed web application is rolled out. (Phase II)

3 URN generation for de-duplicated and valid records by MoLE

3.1 Validation of uploaded data using EDVASP and BDCS software

MoLE 1. Not required, as the web based application would already have valid and de-duplicated data available for URN generation

2. Since all records are already valid, MoLE may decide to do a de-duplication check again

3. MoLE may take a decision on priority category based on duplicate records found

4. The duplicate records pertaining to two different states would be made available to the respective states for resolution

MoLE 1. The de-duplication process and algorithm at the MoLE level would be the same as at the SNA level, i.e. a two stage process and well-defined rules for deduplication. These rules have been prescribed in Annexure 1.2

2. There is a possibility that the duplicate records may come from different states, and in that case, duplicate records which were missed during the SNA stage can be identified at MoLE.

3.2 17-digit URN generation at family record level

MoLE 1. URN generation to be done by the proposed web application after being prompted by MoLE

MoLE 1. This feature would be available once the proposed web application is


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Sr. No


Remarks

done in EDVASP

URN structure

1, 2 – State Code 3, 4 – District Code 5, 6 – Block sequence number 7, 8, 9 – Village sequence number 10,11 – Year of generation 12, 13, 14, 15, 16 – Five digit serial number of family prefixed by zeroes. 17 – Check sum digit

official.

2. Fresh URN should be generated only for new families

3. Data source: Departments will be allowed to enter data on the web application, but MoLE can use data for URN generation only after flagging of data by SNA as “ready for URN generation”

4. Data entry in web application will be either by web application based data entry or upload of MS Access, i.e. .mdb file)

5. SNA will flag a batch of data, only after receiving data from all the departments, preferably after receiving the data for the categories with higher priority

rolled out.

2. The revised format of URN number is as below:

Proposed revised URN structure

1, 2, 3, 4, 5,6 – Census village code

7, 8 – Year of generation

9, 10, 11, 12, 13 – Five digit serial number of family prefixed by zeroes.

14 – Check sum digit

3. The URN number for the family will remain the same

4. In case of family split, a new URN number would be generated for the new family

5. In case of migrants, URN number would still remain the same. The address would change, and the reporting would happen on the address fields.

6. Referential integrity of records with previously allocated URN (associated with new URN) should


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Sr. No


Remarks

be maintained.

7. The families which are not available now would be tagged as ‘inactive’. ‘Active’ families imply those families which exist on ground, but not subscribed (i.e. not under RSBY yet). ‘Inactive’ implies that families reported do not exist on ground. Audit will be conducted on sample basis for reported “active” & “inactive” family to verify the accuracy.

8. The current server capacity is 10 lakh URN generation per week, and the same would have to be enhanced to meet the KPI

9. The URN generation will happen in a pre-defined scheduled format (FIFO)

10. Exception to FIFO, if required, will be allowed only after approval of Project Director at MoLE

4 Providing data (URN generated) to Smart Card Service Provider (SCSP) for enrolment

4.1 1. Encryption of pre-enrolment data, with a hash key provided for each record to

MoLE 1. MoLE will select the SCSP from the Consortium of Public Sector Undertakings (CPSU), which will conduct the

1. MoLE

2. SNA

1. MoLE administrator will provide username and password for empaneled SCSP’s with restricted access only for their district data.


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Sr. No


Remarks

detect tampering

2. Encryption of data file with public key of respective IC/SCSP

3. Upload on RSBY portal for download by IC/SCSP

enrolment process for RSBY.

2. SNA will select IC through an open tendering process at state level. It will tag district(s) to the IC. An IC master would be maintained in the web application.

3. The SCSP will be assigned districts based on the time of initiation of enrolment process. The approval and monitoring committee (A&M) will conduct the sequencing of enrolment process by the SCSP.

4. SCSP will upload the public key after logging into the web application. The enrolment data will

5. The MoLE official who has generated URN would indicate on the proposed web application that the data may now be made available to the SCSP. The SNA would then notify that the data (district wise sets) may now be made available to SCSP.

6. The data made available to the SCSP would only be for ‘active’

3. IC

4. SCSP

2. This feature would be available with the proposed web-based application.

3. The SCSP would not be able to delete any data from the web application.

4. Subscribed means families which are enrolled under RSBY. Unsubscribed families would imply those which have been covered under pre-enrolment, and for which URN was generated, but actual RSBY enrolment did not take place. The families which have not been pre-enrolled would also fall under the ‘unsubscribed category’.

5. The SCSP would have access to all data, depending on the districts where it has been assigned enrolment work.


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Sr. No


Remarks

families who do not have an existing policy (families with existing policies would last for 3 years under normal circumstances. In case of change in IC before the 3 year tenure, there will be policy portability to the next IC with a provision for new policy number)

7. The SCSP will be provided secure access to proposed web application, from where it may download the data (for which URN has been generated). The data would be encrypted with the public key of smart card service provider (SCSP) for data security.

5. Updation of beneficiary data by respective state departments

5.1 Currently, the process of updation of data does not take place

SNA 1. The data of beneficiary can be received from various sources at the field such as in kiosk (where the beneficiary can submit a request for inclusion).

2. Such requests are to be logged into the web application and sent to the respective state

1. Respective state departments

2. SNA

1. The beneficiary data is to be updated every 6 months. The cycle of updation in the months of February and August to be continued.

2. The Welfare Commissioners of the States would be responsible for the respective departments to provide the updated data to SNA, every 6


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Sr. No


Remarks

departments.

3. The state departments shall verify the data of the beneficiary, which shall then be sent to the SNA for inclusion in the beneficiary list.

months.

Policy decisions taken Meeting reference

Sr. No.

Decisions Date/Location/Chaired by:

1 Guidelines and process for selection of category based on prioritization (in case of duplicate record coming from different category) to be finalized as provided in Annexure 1.1)

Meeting held under Chairpersonship of Secretary (L&E) on 6th May 2014, minutes yet to be processed in file

2

Process of de-duplication finalized (as provided in Annexure 1.2). The process should have a 2-stage de-duplication (Alert/Confirmation) and the identifiers on which exact/partial/fuzzy match would happen would be defined. In case of duplicate records identified at the MoLE level, the notification would go from MoLE to the states


3 No RSBY record would be deleted, and the records which are not under the RSBY ambit anymore would become ‘Inactive’. This facility should be available by categories


4. Data of beneficiaries to be updated every six months by the respective state departments. The role of State Welfare Commissioners will be crucial in the process of updating the data of beneficiaries.

EC Meeting held under the Chairpersonship of Secretary (L&E) on 15th May 2014, minutes yet to be processed on file


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Policy Decision to be taken

Sr. No Decisions

1 De-duplication of beneficiary data to be done in two stages - by the data source departments and SNA

2 Category prioritization to be done at the time of de-duplication of data by the SNA

Incentive mechanism

1 NA

Training Needs Training to be provided to

Training to be provided by

1 Training on process of two-stage de-duplication in the proposed web application SNA and departments MoLE

2 Training on selection of beneficiary category prioritization in the proposed web application SNA MoLE

3 Training on pre-enrolment data capture with collection of mandatory fields in the prescribed format

Departments SNA

Human resource requirement Agency / department

1 Team to develop and roll-out the web based application for pre-enrolment and data preparation for enrolment

NIC

2 To add capacity to the SNA as per minutes of the empowered committee meeting held on 15th April 2014 SNA


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Input for RFP/FRS RFP/FRS for:

1 Category Prioritization (Annexure 1.1) / De-duplication guidelines (Annexure 2) to be made a part of RFP/FRS for the proposed web application by MoLE

FRS for Web Application Development Agency (NIC)

2 List of users and roles for the proposed web application FRS for Web Application Development Agency (NIC)

IEC Activities

1 To create awareness among the beneficiaries of different categories to get themselves registered for RSBY (Except BPL, in every category number of beneficiary can be increased at pre-enrolment stage also)

Other considerations

1 Inter-department meeting at a state level to be conducted once every month (1st week of every month) to present and discuss

(i) status, and (ii) plan for pre-enrolment and enrolment. The meeting has to be called upon, and hosted by SNA. The meetings should be used by SNA

to educate the departments of provisions under RSBY.


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Pro

ce

ss

Co

de

II – ENR Process Name

Enrolment

Process Objective Current Status 1. To increase the enrolment numbers for RSBY so that all intended beneficiaries

are covered 2. To educate & empower beneficiaries through IEC activities to utilize the RSBY

services using the RSBY card 3. To strengthen the process to ensure only intended people are getting enrolled 4. To ensure that data arising out of this process is accurate, clean and re-usable

1. ~3.6 Crore active RSBY smart cards

2. All Insurance companies (IC) / Smart card service provider (SCSP) using ECIS software as well as STQC certified Enrolment software for enrolment and card issuance

Key Stakeholders Measures and Key Performance Indices (KPIs) 1. Smart Card Service Provider (SCSP)

2. Field key officer (FKO) for verification for beneficiary and card issuance

3. State Nodal Agency (SNA)

4. District Key Manager (DKM) for creation of FKO’s in the system

5. District Information Officer (DIO)

Measures4: MoLE, SNA, IC/SCSP, DKM, FKO (relevant reports to be available, depending on role) 1. Number of beneficiary cards issued

Filters: Time Duration (from-to), Geography (district/ block/ village), SCSP, FKO, beneficiary category

2. Number of cards wasted Filters: Time Duration (from-to), Geography (district/ block/ village), SCSP, FKO,

KPI5: SNA, SCSP, DKM, FKO (relevant KPI’s to be measured, depending on role) 1. Number and % of enrolment completed at village, district and

state level (the baseline would be the number of pre-enrolment data records)

2. Average family size enrolled (with geography filters) 3. Number of active enrolment kits deployed (with geography


5 All KPI’s to be available as a report on a web portal in real-time/near-real-time. The data should be available in a warehouse, such that any extraction is possible to create ad-hoc reports.


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filters) 4. Average time taken to create/issue an RSBY card – this should

be computed by computing the difference between timestamp on initiation and completion

5. Average time spent on field – computed by the difference between the last enrolment for the day, and first enrolment for the day

6. Number of villages covered by the SCSP 7. Time taken to get the FKO data uploaded on server 8. Number of villages with ‘ZERO’ enrolment 9. Number of FKO’s deployed 10. Number of ‘active’ FKO’s – defined as number of FKO’s who

have done atleast 1 enrolment 11. Number of active enrolment kits deployed

Summary of current challenges Summary of key suggestions 1. Low percentage of enrolment w.r.t. pre-enrolment data 2. Enrolments happening in the latter part of the enrolment time window,

resulting in reduction in effective policy period 3. Non delivery of card to enrolled families 4. Cases of unintended people getting the cards are reported – this is due to

unauthorized use of DKM and FKO cards 5. Non availability of MIS on a near real-time basis to MoLE or SNA for making key

policy decisions 6. Some of the villages completely getting skipped from enrolment process 7. Data coming from different channels are inconsistent, resulting in requirement

of continuous reconciliation

1. Close monitoring of enrolment activity through enhanced reporting across the enrolment lifecycle

2. Concurrent third party audit for ~0.1% - 0.5% cases to be executed by SNA (within one month after completion of enrolment process). The range is valid for every district. The third party audit for enrolment station/kits should happen concurrently, for at least 1% of the enrolment kits deployed. The third party for audit may be the same. The empanelment of hiring of agencies should happen at MoLE.

3. Performance evaluation of SCSP 4. High penalty for villages with “Zero” coverage

Pre-requisites for the process of enrolment 1. Finalization of specifications and procurement of enrolment kit 2. Pre-enrolment data availability with the SCSP 3. On-boarding of IC’s – legal contract between SNA and IC 4. On-boarding of SCSP – legal contract between SCSP and MoLE 5. Hospital empanelment should be completed, and district kiosks should be set up 6. Identification and appointment of FKO & DKM by SNA 7. Procurement and distribution of IEC material by the SCSP 8. A detailed checklist for the enrolment station, attached in Annexure 2.1


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Inputs to the revised process Output from the revised process 1. Pre-enrolment data

1. Issuance of RSBY cards to the intended beneficiaries 2. Collection of fixed fee from the beneficiary by the SCSP (issued

card to act as receipt for INR 30 paid by beneficiary) 3. FKO undertaking form, indicating the number of enrolments

4. Post-enrolment data by SCSP using a web-sync or batch upload to the central server


Sr. No

Current Process Responsibility Proposed Process Responsibilities Remarks

1 Pre-enrolment data availability with SCSP

1.1 1. Downloading the data from MoLE and sharing the data with SCSP for enrolment and card issuance

2. The data is split by

the SCSP as per geographical unit, and the data-sets is copied into the respective enrolment kits

IC 1. MoLE user would create the SCSP in the system. At the time of SCSP creation, the scanned copy of the agreement between MoLE and SCSP would be uploaded for records. An SCSP master would be created at MoLE

2. The selection of SCSP from the SCSP master will be done in the web application and assignment of the district(s) to the SCSP will take place based on enrolment initiation process at state/district.

3. SCSP will upload the public key after logging into the web application

4. SCSP should be a user in the

1. MoLE 2. SNA 3. SCSP

The flow of pre-enrolment data thus follows the following process. State Departments SNA MoLE SCSP in the same web application 1. At every stage, the data will flow to

next stage only after authorization of user

2. In most of the cases the data will move in batches


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proposed web application. The data is made available seamlessly to the SCSP which has been tagged MoLE/SNA for a given geography (district). This is done in the web application.

5. SCSP can download the data for any geographic unit and copy it to respective enrolment kit

2 Verification of beneficiaries at the time of enrolment

2.1 Quality check on the data downloaded from RSBY portal to ensure completeness, sanctity, etc.

SCSP 1. No change to the process of verification

2. Any errors would be reported by the SCSP through the web application to the SNA

SCSP

3 Master Personnel and Card Management

3.1 Identification of DKM SNA No change SNA 1. By default, district level officer of nodal department in state (Labour/Health) will act as DKM

2. DKM will identify one additional person to work as ADKM to support him in routine activities. They may be hired on deputation from government or on contract


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3.2 Identification of FKO DKM No change DKM 1. FKO has to be a person with good knowledge of local area

2. He/She, preferably be working with government department, or may be a member of Panchayati Raj Institution (PRI)

3.3 1. MoLE issues a DKM card (with security PIN) for each DKM after receiving requisition from SNA

2. Card is send to SNA by post, or through authorized person by MoLE officials.

3. SNA handover the cards to respective DKM

1. MoLE 2. SNA 3. DKM

1. MoLE issues the card to SNA, which is handed over to DKM

2. DKM goes to DIO for card personalization

3. DIO has the card personalization kit, including a biometric capture device

4. DIO will personalize the DKM card by capturing the biometrics of DKM

5. After issue of card to DKM, the information would be updated in the web application. This should have details of DIO issuing the card to DKM along with timestamp etc.

1. MoLE 2. SNA 3. DKM 4. DIO

1. This would prevent misuse of card 2. Under no circumstances, the card

should be issued to SCSP or its representatives

3. If in exceptional circumstances the card is sent through a person authorized by SNA, the card box should be properly sealed

4. Details of dispatch and receipt should be updated on web portal both by MoLE and SNA.

3.4 1. Issue of FKO Card (with security PIN) by MoLE on the basis of requisition sent by SNA

2. Cards are sent to SNA, who in turn will send the card to DKM, who will personalize it with fingerprint of FKO

DKM 1. DKM would issue the card to FKO only after his/her own biometric authentication. DIO may also issue cards with same access privileges to ADKM, who are notified by DKM as equivalent officers for issuing FKO cards.

2. DKM/ADKM will personalize the FKO card by capturing the biometrics of FKO and associating it with the card

3. After issue of card to FKO, the

1. DKM (Primary responsibility)

2. Additional DKM (ADKM)

3. DIO

1. This would prevent misuse of card 2. Under no circumstances, the card

should be issued to SCSP or its representatives.

3. If in exceptional circumstances the card is sent through a person authorized by SNA, the card box should be properly sealed.

4. Details of dispatch and receipt should be update on web portal both by MoLE and SNA.


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information would be updated in the web application automatically. This should have details of DKM/ADKM issuing the card, FKO receiving the card, timestamp, etc.

4 Planning for field operations

4.1 1. IC, SCSP and DKM prepare the route plan

2. FKO’s are informed about the route plan

1. IC/SCSP 2. DKM

1. The format of the route plan would be available in the web application. The fields in the route plan would have date, village name, block name, number of kit to be deployed, SCSP personnel name and mobile number, supervisor name and contact details, FKO name and contact details. Additionally mobile number of village key persons (such as Sarpanch, teacher, ASHA, ANM, etc.) should also be captured in the route plan.

2. SCSP should prepare the route plan and digitize it into the proposed web application for access by SNA & DKM.

3. Immediately after submission of route plan, FKO’s have access to the route plan (An SMS/email may be sent to FKO’s) from the proposed web application)

4. Once the route plan is finalized, the system should be pinged for village

1. SCSP (Primary responsibility) 2. DKM

1. For preparing “route plan” , SCSP would take inputs from local functionaries

2. Once approved by DKM, “route plan” should not be changed without DKM’s permission. This will always be managed through the proposed web application

3. Route plan should include a. Schedule of enrolment b. Number of kits to be

deployed c. Every plan upto village level

should be tagged to a DKM and FKO, along with their registered mobile numbers and email addresses. Mobile number would be mandatory.

4. The route plan management would mean access of the proposed web application to one more users, i.e. DKM, This makes the total user set as state departments, SNA, MoLE, SCSP and DKM


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residents in the pre-enrolment data-set, and an SMS should go to the residents of the villagers with registered, mobile number indicating the date of the visit, as well as indicating the number of the FKO who would be the point of contact.

5. SMS/mobile number for notification is mandatory. Email is optional.

4.2 Workshop at block and district Headquarters with identified FKOs and local officials

1. IC 2. SCSP

1. SCSP shall organize the workshop 2. Workshop structure defined by

MoLE should be reinforced, with checklist of hand-outs to be provided during the workshop.

3. In the structure of the workshop, provision of lunch to be included.

4. Route plan may be tweaked in this workshop on the basis of feedback from FKOs

1. SCSP (primary responsibility)

2. Representative of DKM (may be a block level official)

1. In this workshop, FKOs should be made aware of the following: (i) Benefits of scheme (ii) Route Plan (iii) Roles and responsibility of SCSP and FKO during enrolment

2. Beneficiary list is made available to FKO for his/her area

3. FKO’s, while being created by DKM’s in the system, should be tagged to villages so that they can access pre-enrolment data of village beneficiaries

4.3 Route plan is published in the local media

IC 1. Route plan is published in local media

2. The final route plan should be published in local media (newspaper), along with details of supervisors and FKOs. In case of any major change, it should be re-published

SCSP Route plan should be published preferably in a daily newspaper in local language with maximum circulation in that area

4.3 1. Awareness and sensitization

1. IC/TPA 2. SCSP

1. The IEC material preparation should happen in consultation with

1. SCSP (Primary responsibility)

1. SCSP should ensure that beneficiaries are informed well in


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exercise using IEC material at the field level

Primary target: Beneficiaries Objective: 1. To mobilize the

beneficiary for enrolment

2. To make beneficiary aware of benefits available under scheme

3. DKM district/DKM

2. DKM (only signs off on IEC completion)

advance about schedule of enrolment in their villages and wards, through: i. print and electronic media (with focus in districts during the enrolment time window) ii. SMS

2. SCSP should also ensure that beneficiaries are made aware of benefits of scheme through village level meetings, wall paintings, and display of IEC material at village/ward offices or buildings, house-to-house slip distribution with local language content, loudspeaker announcement (munadi)

3. DKM should monitor the awareness and sensitization activity

4.4 Preparation of enrolment kits (EK) with pre-enrolment data, as per route plan. The data is provided in the form of encrypted access (.mdb) files from the central server (RSBY portal)

1. IC 2. SCSP

1. Once the web application is ready, the data splits (based on geography parameters) should happen at the web application level, and copy of data into enrolment kits may also happen from the web application

2. Authorized and secure data modification is permitted through the proposed web application only.

3. The enrolment application should flag for ‘potential duplicate’, depending on the pre-enrolment data copied on the enrolment kit. In case of a potential duplicate, the

1. SCSP

1. Data of a geographic area should be copied in the enrolment kits identified for that area only.

2. ‘Inactive’ records would be based on the guideline that the family does not reside in the village/ward at all. However, if the family is not available temporarily, the record should not be marked as ‘Inactive’. This feature should be made available in the enrolment software.


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SCSP should carefully identify the appropriate record from the list. This investigation should happen by looking at the family members details. A similar pop up should be made available in the enrolment software.

4. At the time of enrolment, a field could be added which would flag a record as ‘active’ or ‘inactive’.

5 Enrolment

5.1 Setting up enrollment station(s) at village enrolment center by SCSP and FKO on the day of enrolment as per route plan

1. IC/SCSP 2. FKO

The SCSP will setup the enrolment stations at the respective villages/ districts.


2. FKO

1. Enrollment station to be set up as per approved route plan.

2. FKO should be available on time 3. All equipment of enrolment kit

should be in working condition, and should be tested before the commencement of enrolment and certified by the DKM. The DKM should also certify that 10% extra/backup kits are available, and the spares available with SCSP are of good quality. The backup 10% of the kits should be in custody of DKM, and should be used by DKM to address complaints from village residents where enrolment does not happen due to any reason. DKM can decide to keep these extra/backup kits at a location near to area where enrolment is going on


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4. FKO should use an enrolment station checklist (Annexure 2.1) to ensure all the required steps have been completed, before allowing commencement of enrolment.

5. In case of malfunctioning of any of the equipment, enrollment should be stopped, until it is replaced. Under no circumstances, partial enrolment should be allowed, it should be considered complete, only if beneficiary has received card after re-verification

5.2 Distribution of “Intimation slip” to beneficiaries

1. IC/SCSP

The SCSP shall distribute the “Intimation Slip” to the beneficiaries.

1. SCSP (Primary responsibility)

IC/SCSP should distribute “Intimation Slips” printed in local language containing URN number, name of family head, names of family members, date of enrolment atleast 48 hours before enrolment

5.3 Enrolment of Family (Family head, spouse and three other members identified by Family head)

1. IC/SCSP 2. FKO

1. Enrolment of family (Family head, spouse and three other members identified by family head), if available, should mandatorily be completed. In all cases, if male head of family is not available, female should be the head of family (HoF)

2. If family head or spouse is not available, then four other members other than family head/spouse can be covered under this scheme.

3. Demographic details all of other members should also be updated in

1. SCSP 2. FKO

1. Once family head presents his/her “Intimation slip”, the operator searches the details of family in database, and captures biometric data (fingerprint & photograph) of every member of family

2. DoB/Age/Gender can be changed at the time of enrolment for all members

3. Name and relationship of all members can be changed, except for head of family

4. Father’s name should be allowed to


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the database 4. If both family head and spouse are

deceased, then based on proof (such as death certificate), the next eldest member of family, preferably female, if available, should be treated as family head. If the name of member selected as HoF is available in database, the card can be issued without any additional verification. If the name is not available in database, matter can be referred to higher authority.

be added or updated 5. There should be an emphasis on

capture of mobile number and Aadhaar number. In case they are not available, ‘0000000000’ and ‘000000000000’ should be captured respectively.

6. The details in the FKO card should include: (i) URN Number (ii) CHIP serial number (iii) Names of all family

members who have been enrolled including HoF

(iv) Enrollment time stamp (v) Age and gender of family

members.

5.4 Printing and Personalization of card

1. IC/SCSP 2. FKO

The SCSP will personalize the card of the beneficiary based on authentication from the FKO

1. SCSP 2. FKO

FKO will authenticate printing & personalization of every card using his biometrics.

5.5 Re-verification of card SCSP 1. Re-verification of card is done with biometric authentication of both FKO and beneficiary.

2. The re-verification information should also go into the FKO card, and signed data in the SCSP kit.

3. Re-verification should be done for all 5 members of the family.

1. SCSP 2. FKO 3. Beneficiary

1. The purpose of re-verification is to ascertain that the finger print captured is of good quality. Currently it does not require authentication by FKO, resulting in by-passing of this important step.

2. Re-verification should be done for all 5 members of the family

3. In case fingerprint of any member is not verified, then his finger print should be recaptured and updated


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on card

5.6 Handing over the card to beneficiary after collecting Rs. 30

1. IC/SCSP 2. FKO

After authentication by FKO, the RSBY card shall be handed over to the beneficiary by SCSP in the presence of FKO. The FKO shall provide for a slip which serves as a receipt of payment of Rs. 30 and the RSBY card.

1. IC/SCSP 2. FKO

1. Once re-verification has been done successfully, card can be handed over to the head of family.

2. Enrollment Software should print a receipt, with receipt number, showing the URN number, names of head of family & other family members and the toll-free number. The receipt should also acknowledge the receipt of Rs. 30 for issuance of the card.

3. The FKO shall provide for the receipt number for each beneficiary in the FKO undertaking form which is to be submitted by him to the DKM office post enrolment. The data from the FKO undertaking shall be entered by the DKM office into the web based software for future reference purposes.

4. The beneficiary shall receive a call from the call center to confirm receipt of card and the receipt from the FKO during enrolment.

5. This is to ensure that the complaints regarding non receipt of cards can be investigated.

6 Post-enrolment activity and premium calculation


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6.1 1. Data upload from FKO card to DKM server at the district (DKMA office)

2. Encrypted signed data of enrollments (text files generated per kit per day) are uploaded by IC at the DKM server (at district/DKMA office)

3. Post enrolment data (csv files) are submitted by the IC/SCSP to the SNA. The process is to submit the data by uploading it on the state /central server. This contains the biometric data as well

4. The photographs and SQL back-up of the beneficiary data is created as SQL files and uploaded by the

1. FKO 2. IC/SCSP

1. Data upload directly from FKO card to MoLE server at the district (DKMA office) using a modified DKM application (instead of first downloading the data at local system) within 5 days from completion of enrolment limit. The member names should be included in the FKO card. From the DKM server, the data should flow back into the central web application server.

2. Encrypted signed data of enrollments (text files generated per kit per day) should be uploaded by SCSP within 5 days on the central RSBY server. This should include biometrics/photograph. Both MoLE and states (including DKM) should have data access from the central server.

1. FKO 2. DKM 3. SCSP

1. This feature will be available after development of web application

2. The provision of capturing time delay in uploading of encrypted data from SCSP in the web application will also be made available.

3. In order to accommodate data for up to 500 beneficiaries at a time, the FKO’s should be given 5 cards each per kit. This will ensure that the enrolment process is not stopped due to limitations of storage on the FKO card.


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IC/SCSP to the state/central server.

6.2 Handover of FKO card by FKO to DKM

FKO At the time of FKO card surrender by FKO to DKM, a system printed MIS report will be provided with the following information (i) URN numbers (ii) Head of family Name (iii) Date of card issuance. The report heading should have the following information (i) FKO information – name, address, mobile number (ii) village name.

FKO This is also to ensure that the complaints regarding non receipt of cards can be investigated.

6.3 No provision of audit post enrolment

Concurrent audit on randomly selected villages for up to 1% villages. - Audit to capture whether

beneficiaries received the card - Quality of card and chip

SNA 1. Audit agencies selected by MoLE /NGO or Pensioners can be employed to conduct random audits on enrolment activities

2. Checklist for post enrolment audit to be prepared as a guideline for audit agencies.

6.4 Wellness check is not included as a process for premium payment to the insurance company

Wellness check at nearest public health facility should be mandatory for the beneficiary and it will be the responsibility of the insurance company to ensure that all the beneficiaries have got their wellness check done within 60 days of start of policy.

IC (Primary responsibility)

Wellness check will be an optional activity for states which are prepared now (1st July 2014). From FY 2015-16 it will be a mandatory requirement for as well as existing cards.

6.5 Premium calculation 1. On the basis of

number of cards, as claimed by IC

2. Premium to be paid for full year

IC 1. If card is issued before policy start date, full payment will be payable to IC

2. IC, however, can claim premium for only those cards, for which wellness check has been completed

SNA The details of data flow and management during, wellness check, and premium payment are discussed in “Wellness Check and Premium Payment” process document.


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even if the card is issued late

3. Wellness check has to be completed within 60 days from start of policy

4. Responsibility of getting the wellness check done lies with IC. If it is getting delayed, penalty will be levied at following rate:

a. Wellness check is conducted after 2 months; penalty levied is 50% of premium for those beneficiaries whose wellness check is remaining.

b. Wellness check is conducted after 6 months; penalty levied is 100% of premium for those beneficiaries whose wellness check is remaining

5. The payment of premium should be done quarterly to the IC.


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Policy Decision taken Meeting reference

Sr. No Decisions

1 Wellness check to be made mandatory for activation of cards EC meeting dated 23.01.2014

2

Incentive to FKO: As of now some of states are paying incentive to FKO for managing the enrolment exercise. It is proposed that the incentive should be higher if the conversion is high. An indicative slab-wise rate is given here for SNAs.

for first 50% @ INR X per data, for next 20% @INR 1.5X per data and above 70% @ INR 2X per data and so on.

SNA can decide about exact rate and slab and appropriately reward the FKO’s post the enrolment process.

Meeting held on 06th May 2014, chaired by Secretary (L&E), minutes yet to be processed in file

3 In case of absence of both spouses, card should be issued with next eldest female member (younger than original HoF) as HoF, provided her/his name appears in the database.


4

Mobile number for all beneficiaries to be collected so that 2 SMS (one in English, one in local language) are sent to RSBY beneficiaries at every transaction. Depending on the transaction, dynamic SMS templates in English and local language should be prepared and approved by MoLE. While mobile number should not be mandatory for the head of family, the data capture should ensure that ‘0000000000’ should be captured so that the data entry operator is not incentivized to leave the field blank. The same should be followed for Aadhaar number.


5

Concurrent third party audit for ~0.1% - 0.5% cases to be executed by SNA (the audit should start within one month after start of enrolment process). The range is valid for every district. The third party audit for enrolment station/kits should happen concurrently, for at least 1% of the enrolment kits deployed. The third party for audit may be the same. The empanelment of hiring of agencies should happen at MoLE.



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Decision to be taken

Sr. No Decisions

3 Use of MMS for monitoring the IEC at Enrolment center. IC can capture place, time and date stamped pictures of FKO in front of IEC material used and upload it.

4 Use of Audio Visual Clip for IEC at the time of enrolment

Incentive Mechanism

1 FKO incentive should be slab-wise. An indicative slab-wise rate is given here for SNAs. 1. for first 50% @ INR X per data, for next 20% @INR 1.5X per data and above 70% @ INR 2X per data and so on. SNA can decide about exact rate and slab

2 SCSP: Performance matrix should include all the KPIs listed above, an objective assessment of performance will give an edge to the performing SCSP

Training Needs Training to be provided to Training to be provided by

1 Roles and responsibilities of FKOs at Enrolment Centre

FKOs IC/SCSP under supervision of SNA/DKM

2 Using Enrolment Software Enrolment Operators / Supervisor SCSP

3 Post enrolment FKO and DKM procedures to be adopted

DKM, FKO and SCSP SNA


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Human Resource Requirement Where

1 Monitoring and Evaluation team, to closely monitor the progress of enrolment, ensure data accuracy and resolve any data conflict issues.

SNA

Input for RFP/FRS

1 Specifications for enrolment kit For empanelment of SCSP

2 Complete process flow of enrolment till premium payment For RFP to empanel IC

3 Content of Brochure to be distributed among beneficiary For empanelment of SCSP

4 IEC activity to be carried out For empanelment of SCSP

5

Various Incentive / penalty mechanism

1. Incentive for FKO

2. Penalty for delay in wellness check

For RFP to empanel IC

6 Performance Matrix

For RFP to empanel IC

Separate performance matrix for SCSP pertaining to its role in enrolment

IEC Activities

1 Publicize the dates of enrolment in the district / block

2 Benefits of Scheme to increase awareness among the target beneficiaries


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P

roce

ss

Co

de

III – SKMS

Process Name Smart Card and Key Management System

Process Objective Current Status 1. To create a secure and convenient environment for beneficiary transactions

using RSBY smart card 2. To ensure security of transaction data from unauthorized read or write access 3. To ensure that all beneficiary cards are personalized through authorized and

authentic personnel, master cards and equipment 4. To track all master smart cards throughout their life cycle to ensure that there

is no unauthorized usage or wastage of cards

1. Centralised procurement of master key cards by MoLE (CKGA)

from vendor identified by NIC, and empaneled by NICSI

2. Procurement of beneficiary smart cards by Smart Card Service Provider (SCSP), embedded with certified SCOSTA OS, and delivered to beneficiaries by Smart Card Service Provider (SCSP) in presence of Field Key Officer (FKO)

Key Stakeholders Measures and Key Performance Indices (KPIs) 1. National Informatics Centre (NIC)

2. Ministry of Labor and Employment (MoLE)

3. Central Key Generation Authority (CKGA)

4. District Informatics Officer (DIO)

5. District Key Management Agency (DKMA)

6. Field Key Officer (FKO)

7. Kiosk User(s)

8. Hospital

9. Public Health Facility (PHF)

10. Other departments collaborating with MoLE on similar beneficiary programs

Measures6: MoLE, SNA, DKM, FKO (relevant reports to be available, depending on role) 1. Number of master key cards issued

Filters: User Category (CKGA, DIO, DKM, Kiosk, Hospital, FKO etc.), Time Duration, Card Validity, Geography

2. Number of master cards surrendered, new cards personalized Filters: User Category, Time Duration. Geography

3. Total number of beneficiary cards issued Filters: User Category, Geography, Time Duration, Card Status (Active, Inactive)

4. Number of beneficiary card transactions Filters: Transaction type, Geography, Time Duration, Hospital/PHF, Block/District Kiosk



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KPI7: SNA, DIO, DKM, ADKM, FKO (relevant KPI’s to be measured, depending on role) 1. Average master card utilization (depending on master card,

beneficiary cards issued, other cards personalized)

2. Number of reported cases of lost cards, card tampering in CGRMS

3. Number of corrupt/non-functional cards reported in CGRMS 4. Quality score of beneficiary cards (identified during the third

party audit) 5. Time delay in delivery/receipt of card after card request

(timestamp to be managed in card issuance systems, i.e. KMS and enrolment kit)

Summary of current challenges Summary of key suggestions 1. Sub-standard beneficiary cards are being procured and issued by IC/SCSP

resulting in high number of manual override 2. Master cards / beneficiary cards are not tracked throughout their lifecycle,

leading to poor/no information visibility at MoLE and SNA, making it difficult to know about the issues prevailing in field

3. DKMA cards are being misused due to lack of biometric authentication in DKMA cards, resulting in creation and handover of FKO cards to unauthorized personnel

4. Significant cases of cards being transferred from MoLE to states/districts by IC personnel

5. Wastage on beneficiary and FKO cards 6. Inconvenience to SNA and other users (Hospital, etc) to travel to MoLE, Delhi

for collection of master cards 7. Non-functioning of cards on field

1. Empanelment of beneficiary card vendors / SCSP centrally by MoLE

2. Use of key management system, to ensure use of Smart cards manufactured by empaneled vendor only

3. Use of Web-based KMS application for master card requisition, master card issuance and real-time report generation to ensure that without electronic requisition and approval, no master card is issued. Detailed SRS for online KMS application needs to be prepared by the IT agency.

4. Card personalisation to be decentralised, DKM/ADKM card to be personalised at districts by DIO. DKM / ADKM card can be used only with biometric authentication.

5. More data fields (mobile, Aadhaar number, NPR number ) to be captured in FKO card at the time of beneficiary enrolment and card issuance



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6. FAQ’s on non-functioning of cards and devices to be made available on RSBY website, with details of ICs, SCSPs, and technical support team

7. Immediate deployment of Centralized technical support team (with availability of email, web and phone numbers) across entire IT solution portfolio, including central web application, KMS, TMS, CGRMS, card/biometric issues. To be integrated, eventually, with call centre, which will act as front-end for technical support, as well

8. A guideline to limit wastage and handle waste cards is to be prepared and enforced

9. Introduction of system audit, at least once per annum and on major changes in the system, to ensure that the key management and master card management processes are being followed

Pre-requisites for the process of enrolment 1. Card specifications 2. Pre-enrolment data

Inputs to the revised process Output from the revised process 2. Identification of prime CKGA user

1. Real-time inventory of all master and beneficiary cards on field, and relevant usage reports


Sr. No


1 Creation of Key Authority Card

1.1 Procurement of card by MoLE through a vendor identified by NICSI with OS prepared by NIC

MoLE No Change MoLE Since this card will be used for carrying and deriving keys, the OS has to be internal to NIC, hence it should always be procured internally through an identified vendor only


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Sr. No


1.2 Creation of Seed card of CKGA and 5 more members (Seed Members) Any 3 members, plus CKGA required for generation of master card Verification mode: PIN (6-8 characters alphanumeric)

MoLE 1. For any master card issuance authentication of 3 seed members out of 5 along with CKGA will be required

2. For all 5 seed members (excluding CKGA), mode of authentication will be biometric. For CKGA, however, authentication will be through PIN only

3. Card creation will continue to be in batch mode, authorization will be required only to start the session for a batch. A session can be initiated by CKGA and any 3 seed members out of 5.

4. The session should be active till all approved requisition cards are printed. In case of session break, it can be reinitiated only by CKGA along with 3 seed members

5. In case of any officer from the seed team leaving, the CKGA should be allowed to update the card with new member details, as well as biometrics of new member. The trail of previous member will have to be maintained in the web based KMS system.

MoLE At the time of requisition, the requestor (DIODKM/SNA etc.) would indicate the address where the card shipment is to be delivered. He/she can also indicate that the delivery/collection is to be done manually (by hand). 1. The approver can approve all requested

cards, or less, as deemed fit. The requisition and approval will both happen using the web based KMS system.

2. The web based KMS system should continue to capture issuance of all master cards automatically for information visibility. It would also update the inventory system.

3. The card personalization activity should be carried out in a physically secured environment.

4. As MSK Cards are the root of nationwide KMS, there should be disaster recovery backup sets of the MSK Cards to be used in case of damage/disaster. These disaster recovery locations shall be decided by MoLE.


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1.3 Estimation of number of DKM cards required in state

SNA 1. Users will estimate the client requirements, and make the requisition through the web based KMS system. The DKM users would make a requisition, and SNA would approve the request in the online requisition module of web-based KMS.

2. The SNA, before approval,

may increase/decrease the number of requested cards in the system.

3. The request, approval and

actual printing would happen on FIFO basis. CKGA, however, will have authority to change the priority through KMS web application

4. Once approved, MoLE would

be able to see the requisition. An email/SMS would go to the CKGA. This email should also indicate the expected date of dispatch.

5. At the time of master card

generation, during peak period, the number of kits for master card issuance should be increased. The base

SNA/DKM and system based

All state and district users (One each at state and district level) would have access to web based KMS system for online requisition. General requisition guidelines are: 1. 1 DIO card will be issued for every district 2. 1 DKM card will be issued for every district 3. 1 ADKM card will be issued for every

district 4. 2 Kiosk card will be issued for every kiosk 5. 5 FKO card may be issued for each kit. The

actual number however will be decided on the basis of number of kits to be deployed at any given point of time.

6. 1 Hospital cards for each hospital 7. 1 PHF cards (for wellness check) for each

PHF 8. Application creation card (APCC), as

required by other departments, after approval from SNA

9. DKM will be custodian for all the cards available at district. It will include

a. Additional ADKM, MHC, MKC &FKO kept at district

b. FKO card returned after field operation

10. DKM should be provided with a fire-proof secured vault to keep the card safely and securely.

11. ADKM should be a gazetted officer


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capacity should be 1.5 lakh cards printing in 200 days, i.e. 750 per day. Current capacity is 250 cards per day per kit.

1.4 Send request for DKM, Master Hospital Card (MHC), Master Kiosk Card (MKC), FKO Card, PHF Card to MoLE

SNA Requisition to be done through web-based KMS as described above

SNA Requisition for cards should be sent well in advance. Indicative deadline for sending different category of cards is given below 1. DIO/DKM/FKO Cards: 6 months before

start of enrolment 2. MHC/MKC: one month after onboarding of

IC 3. PHF Card: Before start of enrolment

1.5 Creation of DKMA Card Verification Mode: PIN Using Any of the 3 seed cards along with CKGA card

MoLE 1. Creation of DIO Card and DKM/ADKM cards using any of the 3 seed cards (with biometrics of seed members) along with CKGA card Verification Mode: Biometrics for seed members, PIN for CKGA

2. The DIO card would be personalized with PIN at CKGA. The DKM/ADKM cards will not be personalized, but district names would be written in chip and printed on card

3. DIO card will be sent by MoLE to DIO.

4. The DKM and ADKM cards will be sent to either SNA or DKM, as per address provided at the time of requisition.

5. Once the DKM and ADKM have

1. MoLE 2. DIO 3. SNA 4. DKM /

ADKM

1. Mode of transfer of DIO cards directly to DIO should be registered/speed post, or by hand through authorized government official. The officer responsible for the transfer should be CKGA.

2. Mode of transfer of master cards from

Delhi to SNA/DKM should be registered/speed post, or by hand through authorized government official. The delivery address would be as per address mentioned in requisition.

3. All DIO’s, DKM’s and ADKM’s should have

access to web-based KMS, and should also have personalization equipment (laptop, biometric device, 2 card readers, paper printer, camera). The issuance of cards should always happen using the web-enabled KMS in a connected mode.

4. Whenever a DKM or ADKM go to DIO with a


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received their cards, it should be indicated on the web portal. DKM and ADKM would carry their card and go to DIO for biometric personalization. The DIO will personalize the cards for ADKM and DKM by capturing biometrics and other details. The authentication of DIO card would be through PIN.

6. In case of transfer/change of DKM/ADKM, the new DKM/ADKM would go to DIO with the card and get the personalization details and biometrics updated. The same would take place using the web-based KMS so that the latest information is available to MoLE.

7. After biometric personalization, DKM/ADKM would take the card from DIO.

card for personalization, they would carry an authority letter.

5. The registered mobile number of all DIO’s,

DKM’s, ADKM’s, FKO’s would be captured during user creation and made available in the master table.

6. In case of change in mobile number, its

responsibility of concerned user to get it updated in the system

1.6 1. Master Hospital Card (MHC), Master Kiosk Card (MKC) are issued from MoLE (with hospital/kiosk unique code) to SNA

2. SNA sends it to DKM, 3. DKM sends it to

hospital/kiosk

MoLE SNA DKM

1. No change in issuance. 2. MHC,MKC cards would be

issued at MoLE, with code and name of entity printed on it and sent to DKM

3. 10% additional blank cards will be prepared and sent to DKM

4. DKM would personalize the cards and distribute it to Hospitals/Kiosks.

5. In case of loss/damage of

1. DIO 2. DKM/ADKM

1. PIN and PUC of the respective cards will be printed and dispatched by DKM/ADKM/MoLE only.


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cards, DKM will provide duplicate/replacement cards from inventory of Blank cards.

6. Name and code of entity can be printed using card printer at Kiosk

1.7 1. FKO card is printed and dispatched to SNA by CKGA at MoLE. The card has district and state codes in the chip and printed on face

2. SNA send the cards to respective DKM

3. DKM handovers the cards to FKO after personalizing it using DKM card and PIN.

DKM 1. FKO Card would be printed and dispatched to DKMA by CKGA at MoLE

2. DKM/ADKM would hand-over the card to FKO after personalization. Each personalization would require biometric details of FKO.

DKM/ADKM 1. SNA would monitor the card movement through web based KMS system.

2. Under no circumstances DKM/ADKM/FKO cards should be shared with IC/SCSP.

2 Procurement, personalization and issue of Beneficiary card

2.1 Specifications of beneficiary Cards

1. 64 KB card 2. SCOSTA certified

MoLE No Change MoLE 1. Since the card will be used for 3 years, quality of the card should not be compromised.

2. Choice of material and certification for cards should be done on the basis of available capacity in the market.

2.2 IC Procures the cards as per specifications decided by MoLE and provided in RFP

IC 1. MoLE to empanel vendors (SCSP) for procurement of cards

2. Vendor to manufacture special lot of cards, specifically for RSBY

3. SCSP to procure cards from

SCSP 1. MoLE to provide a key (transport key) to all empaneled vendors.

2. Vendor to inject transport key in all Smart Cards, manufactured for RSBY

3. ECIS /Kiosk application would be modified accordingly to allow, personalisation of cards with transport Key, only.


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empaneled vendors only

2.3 1. SCSP personalizes the beneficiary card after biometric authentication of FKO along with FKO card

2. Details (URN, Card Chip number) of all the cards issued is captured in FKO Card

3. At the end of enrolment session, signed data is generated for uploading to DKM server.

1. IC/SCSP 2. FKO

1. No Change in personalization process.

2. All the cards wasted at the time of personalization should be hot-listed in the chip as well as in the database.

3. Details of cards hot-listed should be captured in FKO cards.

4. At the end of enrolment session, signed data is generated for uploading it through web application

5. FKO Card data to be uploaded by DKM through the web application

1. IC/SCSP 2. FKO

1. FKO card would capture following additional details

a. Name of head of family b. Date with time stamp c. Number of family members

enrolled d. Name of family member

enrolled e. NPR Number f. Aadhar Number g. Mobile number

2. Increase in number of fields to be written in FKO card will warrant issuance of more number of FKO cards for each kit.

2.4 1. IC/SCSP updates its database with all the cards issued

IC/SCSP 1. Signed data will be uploaded through web application

2. Card chip number, time stamp and other demographic details, if updated during enrolment will be updated in central database.

3. Data from FKO card would also be updated in central database

SCSP 1. The data received from two independent secured sources (FKO Card and signed data) would be used to update the database.

2. MIS of cards issued will be available on near-real-time basis.

3 Other activities

2.6 Issuing duplicate card 1. Hot-lists old card 2. Data updated in

database at IC

Kiosks 1. Hot-list the old card using web based application

2. Update the data of hot-listed cards in local database of all

Kiosk A duplicate smart card with exactly same details and balance is issued in following conditions:


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server 3. IC informs

hospitals about hot-listed cards

empaneled hospital, when they are connected to central / state data base servers.

3. Personalize the card with data available at central server

4. Update the card chip number in the data base,

5. Keep the old card chip number in database

1. In case original RSBY card is lost or

damaged

2. Original card has stopped functioning

2.7 Issue of split card 1. Take the request from

HoF for issue of smart card

2. Check the available limit in card

3. Reduce the existing limit of primary card by amount (X) for which split card is to be made

4. Personalize the split card with a limit X

Kiosks 1. No Change 2. Update the Card chip number

in the central data base through web application,

Kiosks 1. Central database will have details of all the cards issued against a particular URN number.

2. Against a particular URN only one card will be active at a particular time, except in case of split cards, when two cards can be in active state against a particular URN

2.8 Validity of card 1. Card is valid for five

years, policy is valid for 1 year

2. Every year a new card is issued with fresh limit in case the beneficiary data provided by SNA was changed or SNA could not provide old URN

IC/SCSP 1. Card is valid for 5 years and policy can be extended maximum upto 3 years

2. After one year beneficiary will visit the kiosk to reset the limit to 30K, else

3. If beneficiary visits hospital, TMS will check at central data base and update the details of the limit on the beneficiary card.

1. IC 2. SCSP 3. Kiosks

Insurance policy will be valid for one year, and needs to be renewed every year upto a maximum of 3 years based on performance. To renew the policy, beneficiary will have to visit either kiosk or hospital.


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3. In case the renewal data contained the old URN, the same card could be renewed by adding the next policy details

Policy decision taken

Sr. No Decisions Meeting reference

1 DIO to personalize DKM card Letter dated 22nd April 2014 from DDG NIC

2 DKM card to have biometrics for authentication at issuance of FKO card Meeting held on 6th May 2014, chaired by Secretary (L&E), MoM yet to be processed in file

3

All FKO, Hospital, and PHF cards to be personalized and issued by DKM. In absence of DKM, this can be electronically delegated to one or more ADKMs (upto 2) using the web based KMS. The responsibility of the inventory would be with DKM. In addition to delegation of DKM charge, ADKM can also be used for setting up additional DKMA in case of large districts

Meeting held on 6th May 2014, chaired by Secretary (L&E), MoM yet to be processed in file

4

Centralized technical support team across entire IT solution portfolio, including central web application, KMS, TMS, CGMS, card/biometric issues to be established at MoLE. The team can be reached through various channels viz. email, web and phone number. The team for this technical support should be outsourced. To start with the technical support agency will have separate resource and channel of communication (email, number and web channel). In future (at the start of next policy year i.e. FY 15-16), however, they may merge with CGMS.

Meeting held on 6th May 2014, chaired by Secretary (L&E), MoM yet to be processed in file

Policy decision to be taken


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Sr. No Decisions

1 FRS and SRS for web-based KMS application should be prepared at the earliest so that the same can be developed by NIC. FRS to be made by a third party agency. SRS to be made jointly by third party agency and NIC.

Incentive Mechanism

1 NA


1 Awareness and sensitization of master key card holders about criticality of KMS system and to use the new web based KMS system

CKGA, Seed members, DIO,DKM, ADKM, FKO

NIC


1 Additional DKMs to personalize FKO cards District

Input for RFP/FRS Input for RfP/FRS

1 The one time procurement and delivery of kits for DIO, DKM and 5 ADKM’s (laptop, biometric device, 2 card readers, paper printer, and camera) for card issuance and personalization. Once procured and delivered, the kit would become the property of the SNA.

RFP forSCSP

2 The specifications of card, issuance and personalization equipment and enrolment kit will be defined in the RFP. RFP for SCSP


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Input for RFP/FRS Input for RfP/FRS

3 Additional field to be captured on FKO cards FRS for KMS

IEC Activities

1 Not required


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Pro

ce

ss

Co

de

IV–WCPP Process Name

Public health wellness check and payment of premium

Process Objective Current Status 1. To inculcate the health seeking behaviour amongst

beneficiaries 2. To ensure that one member of the beneficiary family

undergoes timely and hassle free wellness check 3. To ensure accurate and timely calculation of

premium to the insurance company for activated RSBY cards

4. To ensure timely, accurate and hassle free payment of premium to the insurance company

1. Wellness check is a new feature being introduced for the beneficiary. This will ensure that at least one member of the family has undergone a wellness check at the public health facility (PHF / hospital).

2. The IC follows a manual process for raising an invoice to the SNA for payment of premium

Key Stakeholders Measures and Key Performance Indices (KPIs) 1. Beneficiary 2. Ministry of Labor and Employment (MoLE) 3. State Nodal Agency (SNA) 4. Insurance Company (IC) / Third Party Administrator

(TPA) 5. Public Health Facility (PHF) 6. Hospital

Measures8: MoLE, SNA, PHF, Hospital, IC/TPA (relevant reports to be available, depending on role)

1. Number of beneficiary wellness checks vs number of enrolments Filters: User Category (Beneficiary, PHF, Hospital, IC/ TPA), Geography, Time period of wellness check

2. Number of beneficiaries whose wellness checks have been conducted at PHF /

hospital Filters: User Category, Geography, Time period of activation

3. Number of cards for which timely payment of premium has been done to the insurance company by SNA Filters: User Category, Geography, Time of payment

4. Number of cards for which timely payment of premium has been done to the SNA by MoLE Filters: User Category, Geography, Time of payment



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KPI9: MoLE, SNA, PHF, Hospital, IC/TPA (relevant KPI’s to be measured depending on role)

1. Number and % of beneficiaries that have visited the PHF / hospital for wellness checks by the due date (from date of commencement of policy, i.e. 60 days)

2. Number of beneficiaries whose biometrics have been recorded by the PHF /hospital during wellness checks

3. Average time taken by SNA to release payment to insurance company (SNA and

central share) 4. Average time taken by MoLE to release payment to SNA (central share)

Summary of current challenges Summary of key suggestions 1. Uncertainty on card actually being issued to

beneficiary 2. Poor health seeking behaviour of beneficiaries

having an RSBY card 3. Delayed payment to Insurances companies, and

coordination gaps between SNA and Insurance companies

1. Introduce wellness checks for beneficiary with predefined health parameters 2. Responsibility of mobilising beneficiaries for wellness check lies with IC 3. Full premium will be paid for all card issued, but only after completion of wellness check. 4. If wellness check is delayed by more than 60 days after commencement of policy, a

penalty will be levied on IC at following rate: a. If done after 60 days but before 90 days: Penalty will be 50% of the premium of

remaining beneficiaries whose wellness check is yet to be done b. If done after 90 days: penalty will be 100% of premium of remaining beneficiaries

whose wellness check is yet to be done 5. Wellness check being a new concept needs to be driven by IC with support of SNA/DKM/

FKO 6. Definition of health parameters within the wellness check activity needs to be updated

based on the health trends observed

Pre-requisites for wellness check and premium payment 1. Beneficiary to be issued the card during the enrolment process 2. PHF should have equipment, software and appropriate connectivity to update the database and card with wellness check data 3. Hospital has performed wellness check as per the wellness check activities laid out in Annexure 4.1

Inputs to the revised process Output from the revised process 1. Beneficiary card activation details

1. Wellness check of beneficiary 2. Confirmation of wellness checks performed by PHF / hospital 3. Payment of premium to insurance company



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Process and responsibilities

Sr. No

Current Process Responsibility Proposed Process Responsibility Remarks

1 IEC activity by IC for wellness checks at PHF

1.1 NA (No current process exists)

NA IC and SCSP shall conduct IEC activities for making the beneficiaries aware of wellness checks at PHF.

Reminder SMS messages to be sent to beneficiaries to get their wellness check conducted after issue of card, 1 month before the due date, and 10 days before the due date

1. SCSP

2. IC

3. MoLE

1. SCSP should provide information brochures along with the RSBY card during the enrolment process. These information brochures shall be handed over to the SCSP by IC before the enrolment process commences. A section on the wellness check details should be included in the brochure. The card cover should have the due date for wellness check printed on it.

2. The SMS shall go from MoLE from the URN / enrolment data available at the central server.

2 Wellness check of the beneficiary

2.1 NA NA Beneficiary visits PHF / hospital for wellness check with RSBY card

Beneficiary / PHF 1. One member of the family visits the PHF / hospital for wellness check. This could even be the head of family or any other enrolled member of the family.

2. Responsibility of mobilising beneficiaries for wellness check lies with IC

3. Full premium will be paid for all cards

issued, but only after completion of


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wellness check.

4. Delayed wellness check will attract

penalty from the premium payable to

IC.

2.2 NA NA PHF / hospital performs wellness checks as laid out in Annexure-4.1

The components of the wellness check mentioned in Annexure 4.1 are basic level tests which can be performed by any PHF / hospital. The PHF / hospital must ensure that they are conducting all the tests and uploading the report on the central server. The PHF should also store minimum details of wellness check on the beneficiary card as laid out in Annexure 4.1(a). The larger details of wellness checks should be uploaded on the central server.

2.3 NA NA 1. After the wellness check is conducted, the PHF / hospital operator enters the details of the wellness check conducted into the new web based transaction management software (new TMS).

2. The status of wellness check should also be updated into the beneficiary card by the

PHF / hospital 1. The details of checks performed towards wellness check by PHF / hospital are entered into the proposed web based TMS, hosted on central server.

2. In the event of no connectivity at the PHF / hospital, the PHF/hospital would be responsible to transfer details of all the wellness checks completed by it at the central server


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PHF/hospital operator for keeping a medical record of the beneficiary.

3. Part of the medical details (listed in annexure 4.1.a) of beneficiary will be updated on card.

every 15 days. After 10 days the software would prompt for records which need to be updated in the central server.

3. 4 kb of space at card will be earmarked for Electronic Medical Record (EMR) of beneficiary

2.4 NA NA The beneficiary shall provide his biometrics at the PHF / hospital to confirm his visit for wellness check

1. Beneficiary,

2. PHF / hospital operator

1. The biometric of the beneficiary is taken post completion of the wellness check activity. This will confirm which member of the family has visited the PHF / hospital for a wellness check. This process will also help in creating a health history of the beneficiary for future references.

2. An SMS would go to the beneficiary from the central server, confirming the completion of wellness check and along with card balance details and a feedback shall also be sought from the beneficiary regarding the wellness check conducted.

2.5 NA NA 1. The beneficiary is provided with a print of the results of the wellness check.

2. There will be two prints, one

PHF/hospital 1. The PHF/hospital shall maintain pre-printed report forms, which can be downloaded from the RSBY website.

2. For test results, which are not


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which is instantly available, and one which is available after 1-2 days afterdetailed test results are available.

available instantly, the PHF / hospital would maintain a printed record and the beneficiary should be allowed to collect the test results within 30 days of the wellness check. The beneficiary would be notified by SMS on the availability of his/her wellness check test results.

3 Upload of wellness check report

3.1 NA NA The PHF / hospital should upload the wellness check report of beneficiary on the proposed web based application (new TMS), which is stored on the central server.

PHF/ hospital 1. Uploading of the report is mandatory after test results are available. If possible, the PHF/hospital operator should upload it immediately.

2. “Premium payable” flag should also be updated. In most cases, it should be TRUE, but if it is FALSE, the same information should be uploaded.

4 Premium payment to insurance company (IC)

4.1 Collection of INR 30 from beneficiary after handing over the RSBY card during enrolment process.

IC/SCSP The amount of INR 30 should be collected only after re-verification of cards at the enrolment station.

SCSP (Primary responsibility)

1. The verification of the receipt of cards by the beneficiary is done at the enrolment station. The beneficiary provides his biometric data towards confirmation of receipt of card.


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2. In the first year, the SCSP or its representative shall collect the first instalment of the premium for providing the insurance cover, i.e., a sum of Rs. 30 (Rupees Thirty Only) from each beneficiary family unit, at the time of enrolment and on delivery of the smart card.

4.2 1. IC manually raises an invoice to SNA for the remaining premium (i.e. state and center share) for all cards that are issued.

2. The IC needs to enter the

details of the premium bill raised on the RSBY portal. A Premium Claim Reference (PCR) number will be generated by the system.

3. This PCR number should

be mentioned on the bill submitted to the SNA. The SNA does not accept the bill without the PCR number.

IC 1. The web based application shall fetch data from the PHF / hospital for all the cards that have been where wellness check has been confirmed. The IC can generate an MIS for all such cards and raise an invoice accordingly to SNA for payment of premium from state and central government.

2. The IC will raise the invoice for all such cards through the proposed web based application itself so that there is an electronic invoice record. However, a printed invoice will also be sent to SNA.

3. The proposed web application would generate a unique PCR number for every invoice record which would act as

IC 1. The premium amount (state share + central share) is calculated by the proposed web based system depending on beneficiary category.

2. While calculating premium, following penalty provisions should be kept in mind

3. If wellness check is delayed by more than 60 days after commencement of policy, a penalty will be levied on IC at following rate:

a. If done after 60 days but before 90 days: Penalty will be 50% of the premium for remaining beneficiaries whose wellness check is yet to be conducted.

b. If done after 90 days: penalty will be 100% of premium for remaining beneficiaries whose


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reference, and would be mentioned on each invoice.

wellness check is yet to be conducted.

4.3 1. Assuming that A is the total premium cost bid by the IC, which includes the card cost of Rs. 60.

2. SNA calculates and pays the state share as per following formula 25% (A-60)-30. For NE states & JK, SNA uses 10% instead of 25%.

3. Rs. 30 is being retained by the SNA towards its administrative expenses.

SNA 1. The premium amount for the 1st year (state share) of premium is calculated by the proposed web based system with the same logic built into the system.

2. The state share to be paid

during 1st year would be 25% (A-60)-30. For NE states & JK, the central share would be 90% instead of 75%.

3. The SNA shall pay the

premium within 15 business days of receiving the invoice from IC. The payment must happen through the proposed web application. (Or atleast the payment record should be updated in the application as soon as the payment is made)

4. IC should get a notification SMS and email once the state share is paid.

SNA 1. This premium will only be paid for the beneficiary cards whose wellness check has been done and confirmed in the web based application.

2. A unique payment number would be used to update the payment data in the web based system.


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4.4 1. SNA calculates premium amount for payment of the central share of premium to IC as per following formula: 75% (A-60) +60

2. The SNA shall request

MoLE for its share of premium within 15 days of receipt of invoice from IC

3. The total amount that is

to be paid by MoLE towards the premium shall not exceed the amount that is calculated as [0.75 x (750 - 60) + 60]. Any portion of the premium in excess of such amount shall be borne by the SNA.

4. MoLE shall release

premium amount to SNA within 21 business days of receiving a request in the prescribed format.

5. SNA shall pay IC within 7

days of receiving the

1. SNA

2. MoLE

1. The premium amount for the central share of premium is calculated by the proposed web based system with the same logic built into the system, i.e.75% (A-60) + 60. For NE states and JK, the central share would be 90% instead of 75%

2. The SNA shall pay the

premium within 45 business days of receiving the invoice from IC. The process is as follows:

a. The SNA shall request MoLE for its contribution towards the invoiced amount within 5 business days from release of state share. The same would be done through the web application, with the same PCR number.

b. The total amount that is to be contributed by MoLE towards the premium payable on behalf of such RSBY beneficiary family unit shall not exceed the amount that is calculated as [0.75 x (750 - 60) + 60]. Any portion of the premium in excess of such

1. SNA

2. MoLE

1. The premium for the 2nd and 3rd installment will only be paid for the beneficiary cards whose wellness check has been done and confirmed in the web based application.

2. Once the state share is paid, IC is not

required to produce any additional documents/ information for the release of central share.

3. All payments must happen through the proposed web application. (Or atleast the payment record should be updated in the application as soon as the payment is made)

4. A unique payment number would be used to update the payment data in the web based application.


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amount from MoLE amount shall be borne by the SNA.

c. MoLE shall release this amount to the SNA within 15 business days of receiving a request in the web based application.

d. Upon receipt of such amount from MoLE, the SNA shall pay such amount to the Insurer within 10 business days.

4.5 There is no penalty on SNA for delay in payments, except for circumstances where delay is due to payments being withheld.

SNA Delay in premium payment by SNA to IC - SNA will pay IC an interest of 0.5% of premium amount for every 15 days delay if the premium payment is delayed beyond 6 months of the start of policy.

SNA The proposed web based application will calculate the time delay for payment of premium amount by SNA (both state and central share), and a report would be made available on the web application.

5 Premium refund

5.1 No premium refund / discount guidelines

MoLE In case an IC has not performed well in a year, and adjusted claim ratio (claim paid to hospitals + card issuance cost)/total premium received is less than 70%, it shall refund the differential amount to SNA/MoLE. The differential amount is calculated as (claim amount at a claim ratio of 70%) – actual total claims paid.

MoLE The objective of the scheme is not only to enroll beneficiaries but also to make sure that they get the benefit from the scheme. Therefore, keeping this in mind Insurance Company will have to refund a part of premium at the end of the first and second year if the “Claim Ratio” is lower than the threshold.


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Sr. No Decisions

1 In case of delayed payment of premium, SNA will pay interest to IC @ 0.5% of amount for every 15 days delay, if the premium payment is delayed beyond 6 months of the start of policy

EC dated 23rd January 2014

2 Premium payment will be done based on data generated through the software system/application


3

In case an IC has not performed well in a year, and adjusted claim ratio (claim paid to hospitals + card issuance cost)/total premium received is less than 70%, it shall refund the differential amount to SNA/MoLE. The differential amount is calculated as (claim amount at a claim ration of 70%) – actual total claims paid.



Sr. No Decisions

1

Issue related to card activation not happening due to lack of wellness check compliance

- What can be the estimated % of such cases? - Who does this estimation and takes the risk – IC? - What If majority of beneficiaries don’t turn up for wellness check? - Premium slab in the activation happens 60 days after the onset of policy? - Minimum amount of premium that should be paid to IC in case the beneficiary goes to hospital towards the last month of policy?

3 The wellness check has to be done within 60 days from the commencement of policy. The IEC messaging done by the IC should indicate a due date by which the beneficiary should get the wellness check completed. At the time of enrolment and card issuance also, the IC representatives should communicate to beneficiary the due date (and not 60 days).


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Sr. No Decisions

4 If wellness check takes place after the due date, the policy would still be active for beneficiary. The coverage for the beneficiary for the remaining 10 months would be the same.

5 Checklist for wellness check needs to be approved by MoLE. The same is attached in Annexure 4.1, and is being used by Gujarat.

6 Delay in premium payment by SNA to IC - SNA will pay IC an interest of 0.5% of premium amount for every 15 days delay if the premium payment is delayed beyond 6 months of the start of policy. This will be applicable after MoLE has approved of the case

7 Whether premium discount needs to be applied for IC’s which have performed poorly, i.e. below the 70% claim ratio threshold. Whether this policy is required in addition to the already approved refund policy?


1 Training on usage of web based application for premium payment

Hospital Staff / IC / SNA MoLE / IT application agency

2 Training on usage of web application for management of wellness check information

PHF/Hospital Staff MoLE / IT application agency


1 Details on wellness check process, guidelines and data management IC Selection

2 Process, rules and method of payment of premium to IC on completion of wellness check and card activation till due date, and for the period beyond

IC Selection

IEC Activities

1 The insurance company shall have a strong focus on IEC activities due to payment of premium being linked to wellness checks. The RFP can include a list of tentative IEC activities that the IC must focus on.


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2 Wellness check due date information should be mentioned on RSBY card and cover

Incentive mechanism

1 Not applicable

S.No. Human Resource Requirement Where

1

Monitoring and evaluation personnel to closely monitor the progress of wellness checks being conducted, and subsequent card activation and premium payment process, including management of related audit processes

At SNA, i.e. one for every state


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-P

roce

ss

Co

de

V – HOSP Process Name Hospital Management

Process Objective Current Status 1. To ensure efficient and timely management of network hospitals 2. To increase the utilization and efficiency of RSBY healthcare

facilities offered to beneficiaries by network hospitals 3. To provide quality healthcare service delivery to beneficiaries at

hospitals in a convenient, easily accessible and affordable manner

1. The total number of hospitals currently empanelled under RSBY are 10,311 across 29 states and UT’s (data as per the issuance of MHC cards)

2. The distribution of private sector : public sector hospitals is 6093:4218 3. About 5400 hospitals have been verified by IC as active hospitals and only

about 1700 hospitals have been confirmed as active hospitals by the SNAs 4. The list of hospitals tagged upto district and block is published by MoLE

Key Stakeholders Key Performance Indices (KPIs) 1. Beneficiaries 2. SNA 3. IC/TPA 4. Hospitals 5. SCSP

Measures10: MoLE, SNA, PHF/Hospitals (relevant reports to be available, depending on role) 1. Number of hospitals empaneled and distribution across private and public

sector Filters: Geography (state, district, block), type of hospitals (public, private) Facilities available (Different surgeries etc.) Date of empanelment (from), date of de-empanelment (from)

2. Number of hospitals de-empaneled and distribution across private and public sector Filters: Geography (state, district, block), type of hospitals (public, private), Date of empanelment (from), date of de-empanelment(from)

Key performance indicator11: (relevant KPI’s to be measured, depending on role)


11

MIS on all KPIs to be available on a web portal in real-time/near-real-time, with authorised access


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1. Number and % of district and blocks with empaneled hospitals 2. % of cases with authentication failures (manual override) 3. Number of patients treated, number and % of patients treated with

completely cashless hospitalization

4. Number of blocks with less than 2 hospitals empaneled

5. Number of complaints / grievances made against the hospital

6. Number of claims submitted by hospital

7. Number and % of total claims submitted within 1 week of discharge of

beneficiary

8. Average cash payment made by the beneficiary under RSBY – this should be

computed as total amount paid by beneficiaries at a hospital, and the total

number of beneficiaries treated by the hospital. The hospital is expected to

maintain this data (This data would be made available to audit teams and

the call center)

9. Average hospital equipment uptime in a month 10. Average in-patient time

11. Number and % of hospitals that have meet the NABH revised criteria 12. Number and % of hospitals not reporting claims for more than 3 months 13. Number and % of hospitals adhering to RSBY clinical protocols and STGs

14. Number of hospitals empaneled by IC in lieu of de-empaneled hospitals 15. Number of hospitals de-empaneled

All KPI’s would be measured with filters on public as well as private hospitals Summary of current challenges Summary of key suggestions 1. Beneficiaries are denied cashless medical services by hospitals/IC

on several grounds: - Requirement of additional ID proof (in few cases) - Equipment not functional - Amount charged for initiating treatment - Certain services not covered, and/or unavailability of

providers 2. Beneficiaries not aware of the empanelled hospital list, the

requirement to carry RSBY card to empanelled hospitals, and the procedure to be followed at the hospitals

1. Empanelment and de-empanelment of hospitals will continue to be primary

responsibility of IC, under the close supervision of SNA through a web based

system. SNA will also supervise random audits (number of visits per hospital

per month should to be fixed) conducted by independent 3rd party auditor,

to check the facilities available, and services offered by the hospital, till the

entire RSBY system is made transparent. 2. Updation and revision of package rates for procedures to address the cost

escalation and rationality of procedures including additions of procedures

beyond Rs. 30,000.


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3. Claim settlement process is not transparent (with little information visibility on claim status), discouraging hospitals from participating in the scheme

4. Hospitals feel that the package rates are too low for them to offer the necessary treatment, and often opt out of the scheme

5. Hospitals often offer treatments only for procedures which are profitable for them

6. Hospitals often provide unauthorized/inappropriate treatment, either to charge more from the IC and/or beneficiary, or to discourage beneficiaries from availing services under RSBY

7. Hospitals, even if they are interested and eligible, may not come on board, if they are not in good books of IC/TPA

8. IC/TPA may not empanel good hospitals, due to high claims 9. The current TMS does not have the option to capture clinical

indicators for future verifications 10. Lack of transparency and ambiguity in suspension and de-

empanelment of hospitals. 11. Beneficiary has no flexibility to opt out of the hospital once a

procedure is blocked on his card, nor he can go to any other hospital for availing treatment.

3. Transaction software (TMS) at the hospital should have the facility to capture pre-defined clinical indicators and outputs for post facto evaluation.

4. Enhanced education and empowerment of beneficiaries to avail RSBY services, and to communicate complaints /grievances/malpractices to authorities through the call centre (covered under complaints and grievance redressal) or local district kiosk.

5. SMS communication to beneficiaries (within the geographic area such as block) about empanelment and de-empanelment of hospitals

6. SMS communication to beneficiaries in case they have visited the hospital and taken treatment/drugs (in order to prevent fraudulent transactions) at a hospital

7. Publication of procedures and specialities available at a hospital on the RSBY website, in the RSBY brochure, as well as in local media. The same information should also be available with the call center. The user of the web application should be able to search through hospitals, specialities, procedures and FAQs. This information should be made available to public. In addition to this, publication of the hospital performance should also be published on the RSBY portal.

8. Publication of performance of the hospital on the web with respect to RSBY including quality accreditation, adherence to clinical protocols , patient satisfaction etc.

9. Standardization of hardware equipment and software which is maintained at the hospital

10. Mandated minimum standard information to be maintained and provided to the beneficiary by the hospital.

11. In case, a beneficiary opting to discontinue treatment after the package is blocked, facility will be created at CGRMS or at Kiosk for unblocking his card, with intimation to hospital.

Pre-requisites for the process 1. Empanelment criteria, and empanelment of hospitals 2. Creating list of approved packages and package rates 3. List of ailments/treatment excluded from scheme

Inputs to the revised process Output from the revised process 1. List of empanelled hospitals 2. Pre-agreed procedure rates / package rates

1. Efficient and timely delivery of health services to the beneficiary at the PHF /hospital


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3. Premium information 4. SLA’s for the hospital as per contract with the hospital 5. Transparent and responsive de-empanelment / suspension process

for hospitals

Processes and Responsibilities

Sr. No

Current activities Responsibility Proposed Activities Responsibility Remarks

1 Empanelment

1.1 1. SNA provides a list of hospitals available in the area to IC

2. IC adds list of additional hospitals

3. IC/TPA empanels the hospital on the basis of guideline provided by MoLE Empanelment criteria is given in Annexure 5.1

IC/TPA 1. MoLE will publish the empanelment criteria and guidelines (both online and offline)

2. Hospital empanelment will be made self-service where each hospital can apply for empanelment through the RSBY portal (and by post)

3. The empanelment requests submitted online are examined by the district committee and the selected hospital list is sent to the IC. The IC will verify the details submitted by the hospital and empanel the hospital. In case verification does not happen, IC will use the web application to keep the hospital on hold and indicate a reason for

1. MoLE 2. IC/TPA

(Primary empanelment responsibility)

3. District Committee

4. SNA

1. Empanelment implies readiness of hospitals to accept RSBY beneficiaries for treatment, and conduct transactions online.

2. In every district, the district administration will set up a district RSBY committee. This district RSBY committee will be chaired by District Magistrate/ Deputy Commissioner and will have District Key Manager of RSBY as the convener. The Chief Medical Officer will be other member of the committee. This committee can be any existing committee too.

3. Hospitals may apply for empanelment through web-portal. Hospitals will make the entry of their details through an online entry form on the website www.rsby.gov.in. On successful submission of hospital empanelment form, a “Reference Number” will be generated and this can be used further to track the status of their empanelment under RSBY.

4. Based on the RSBY beneficiary population of the district, number of hospitals should be empanelled in each block. This will include both public and private hospitals. There should be at least two hospitals in each block in each of the project districts.

5. There should be at least 5 hospitals at the district headquarter.

http://www.rsby.gov.in/


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Sr. No


hold. The District Committee, however, can override the hold status to approve/select.

4. The final responsibility of empanelment of hospitals would rest with the IC. IC would log into the web application, and create hospital record and details.

5. Any new hospital proposed by IC would be allowed, but the same should be approved by the district committee.

6. The empanelment process should be completed 15 days prior to commencement of policy.

6. There should be at least one hospital for every 8,000 eligible beneficiaries (~2000 families) in the scheme

7. The following specialties shall be available through empanelled hospitals in each district

a. General Medicine

b. General Surgery

c. Obstetrics and Gynecology

d. Pediatrics

e. Ophthalmology

f. ENT

g. Orthopedic

1.2 Bi-partite agreement between hospital and IC

1. IC 2. Hospital

No change 1. IC 2. Hospital

The overall responsibility of empanelment and de-empanelment of Health Care Providers under RSBY will be of that of the Insurance Company, but with support and under the supervision of SNAs and the district

committee. 2 Readiness of operations at hospital

2.1 Hardware installation at hospitals

1. IC 2. Hospital

The SCSP will provide hardware and its installations at the public and private hospitals.


2. Hospital

Hardware must be installed 15 days before commencement of policy. The readiness of hardware is gauged by dummy/test transaction between the hospital and central server.


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2.2 Maintenance of hardware

1. IC 2. Hospital

The SCSP will be responsible for the AMC of the hardware installed at the public and private hospitals. The hardware and software uptime KPI should be measured, and strictly adhered to.


2. Hospital

1. SCSP should ensure that all reported hardware related issues are resolved within the stipulated time as per SLA.

2. SNA should work with NIC to include remote monitoring functionality of the status of hardware.

3. The AMC contract draft, rates and service provider for maintaining the equipment needs to be finalized by the SCSP.

2.3 Transaction Management software readiness. The FTP software for data transfer is developed by MoLE, and the installation is done by IC.

1. MoLE 2. IC

A new software will be prepared by NIC with additional functions: 1. A web based TMS

application hosted at central server

2. All transactions to be online

3. User authentication through login id and password

1. MoLE 2. NIC 3. SNA

The transaction software will capture all the transactions (Registration/admission of beneficiary, blocking and unblocking of package in the card, discharge, pre authorization for unspecified packages, entry of fingerprint override code, treatment given etc.) done using RSBY cards. Hospitals raise a claim using this application, which is shared with SNA, MoLE and IC. New functionality required: 1. Indication of amount in case the package rate shows

NULL 2. Validation of override code given by IC, in case the

beneficiary authentication has to happen through RSBY card

3. The claim number should be visible on the transaction software

4. Status of every claim (including inter IC claims) should be visible to the hospital through the login on the web application, and/or RSBY portal. The information on claims is updated by the IC. The claim information from all hospitals (TMS) should go on the central server, and the respective insurance companies will act on it.


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5. Wellness check status should also be visible to the TMS software after the RSBY card is used for authentication

6. Transaction software at the hospital should have the facility to capture pre-defined clinical indicators and outputs for post facto evaluation. The central server claims module (available through the web application) would have read/write interfaces/APIs for the insurance company to process the claim

7. The central server should have a facility to allow for card balance query, both through web and SMS channel

8. Timestamp for every transaction should be designed in the system, and captured to monitor turn-around-time compliance for every transaction

2.4 Claim Settlement software access with the Insurance company

IC This process is not required, as the same would be handled through a web application as described above.

NA Claim settlement will be done by the IC based on the claim submitted by the hospital. Any dispute in claims will have to be investigated by the district investigation committee along with the IC. Each stage of investigation shall be recorded in the web based software. Approvals and non-approvals will also be done through the web based software. The IC shall be responsible for closing any claims related issues within 30 days of receiving the claim from the hospital.

2.5 Master Hospital card (MHC) issuance

MoLE 1. No change in the issuance process

2. Decentralized process, where SNA and DIO would have additional cards their disposal, which may be personalized for issuance

DKM


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to the hospital.

3 De-empanelment

3.1 De-empanelment 1. If any activity

by the hospital appears suspicious, IC keeps the hospital under watch list, with a notification to SNA.

2. If situation does not improve in a month’s time, IC de-empanels the hospital by writing to DKM.

IC De-empanelment 1. If any activity appears

suspicious from data patterns observed by IC or SNA, IC keeps the hospital under the watch list. The name of the hospital and date should appear under ‘Watch List’ tab in the web based application. The same is visible to the SNA. MoLE would have pan–India access of all hospitals under watch list. The SNA should get an SMS also as soon as a hospital is put on watch list.

2. IC investigators would monitor the situation. If it does not improve in a month’s time, a show cause notice is sent to the hospital by IC. The status of show cause notice would be updated by IC on the web application. The web

1. IC 2. SNA

1. The guidelines and rules/triggers for suspending the hospital for actual de-empanelment will be defined and published by MoLE. Examples are: - More than the expected cases treated under a

specific procedure - High % of manual override cases at the time of

beneficiary registration - Any other fraudulent activity

Detailed lists of triggeres is given in Annexure 5.2. However, these triggers will invoke investigations prior to any suspension activity being undertaken by IC.

2. An SMS is sent to all beneficiaries in the geographic location (block beneficiaries where the hospital is situated) informing about the de-empanelment

3. Hospitals shall continue to provide treatment to the beneficiaries, even during the period when they are placed on the watch-list or during suspension. Alternatively, beneficiaries who are admitted on the day of de-empanelment would also continue to receive the services from the hospital, and the claims for them would be honored by the IC.

4. The IC would be responsible to empanel another hospital in the same geographic location within 1 month.


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application would also provide a template for show cause notice. The show cause notice would be uploaded on the web application, and the hospital primary user would get an SMS on his mobile. The show cause notice would be visible to the SNA also on the web application. SNA would get also an SMS alert about this.

3. If the hospital does not respond in 7 days, the IC de-empanels the hospital, and an SMS goes to DKM and SNA. During the period of 7 days, the hospital would function regularly and all RSBY services, including admission, treatment and claims would be functional.

4. IC would also have special authority to de-empanel the hospital instantly in an extreme scenario. However, such a de-empanelment would


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always be complimented with an FIR. The scanned FIR copy would need to be uploaded on the web application.

4 Hospitalization

4.1 Registration of patient happens with RSBY card authentication by the patient

Hospital 1. The process does not undergo any change.

2. Direct web based data entry through a client with an offline data entry provision. Only in case of connectivity at the hospital, the functionality for authentication of the hospital user should be provided. So that, on an experimental basis, the authentication using login and password based access to the web application hosted on the central server may be tried.

3. Synchronization with the central server will be done once there is connectivity.

4. An SMS would be sent to the beneficiary to confirm the registration.

Hospital 1. The beneficiary can be advised for hospitalization through hospital emergency or an OPD within or outside a hospital.

2. The beneficiary visits RSBY helpdesk and produces the RSBY card.

3. Helpdesk verifies the beneficiary details and registers him/ her (by swiping the card on the PoS machine and verifying the fingerprints).

4. In the event of beneficiary not carrying the card during an emergency, the hospital can admit the beneficiary on the following condition: - The beneficiary or the family members give an

undertaking that if they fail to produce the card at the time of discharge, the treatment by the hospital shall be chargeable to the beneficiary

5. As per current process, a slip is given at the time of registration. This would continue to be provided and is mandatory for the hospital. A compliance check shall be done by the audit agencies through a random audit.

6. If the hospital demands out of pocket expenses for some reason from the beneficiary, the details of such out of pocket expenses shall be entered in the TMS and a receipt be provided to the beneficiary. The same shall be validated by the call center and the


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audit teams during a random audit. Any hospital found guilty of wrongly charging out of pocket expenses shall be de-empaneled and fined as decided by the SNA/ district committee.

7. In the event that the hospital refuses treatment to the beneficiary, the same will be logged on the TMS with authentication from the beneficiary along with reasons. The investigative committee shall look into the matter of refusal of treatment and will approve of the refusal if the reasons entered by the hospital are found valid. If the hospital is proved wrong post investigation, it shall be de-empaneled and a fine shall be invoked. The IC will de-empanel such a hospital on the report of the investigative committee.

8. On discharge, the beneficiary should be provided with a detailed discharge summary including all expenses charged to him by the hospital along with all claimed expenses. This shall be generated through TMS and shall also be available to MoLE/ SNA/ IC for every beneficiary that has been provided treatment at the hospital. It is mandatory for the hospital to maintain and provide such details, else the claims shall be rejected by the IC.

4.2 1. Blocking the package and amount in the card

2. Hospitalization and selection of package

Hospital 1. No change in process 2. Indication of amount in

case the package rate shows NULL. This will be modified in the new software (web application with offline module) so that amount can be inserted in case it shows

Hospital If advised admission, a second transaction is conducted 1. By swiping the card 2. Verifying the beneficiary through fingerprint

authentication 3. Treatment code is selected from the package list and

amount automatically blocked by the software 4. Insurance company/ TPA receives the intimation

when the day’s transactions are uploaded through the provided utility.


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NULL or it gets displayed once the IC provides the pre-authorization code to the hospital.

3. SMS would be sent to the beneficiary

5. As per current process, a slip is given at the time of

package blocking. This would continue to be provides

and is mandatory for the hospital. A compliance

check shall be done by the audit agencies through a

random audit.

If transaction system is not working or the card cannot be authenticated, the insurer’s district representative should be called immediately and informed of the same.

4.3 Pre-authorization request for treatment which is not a part of approved package list (email / fax approval by IC)

1. Hospital 2. IC

1. If the treatment required is not part of approved package list, request for pre-authorization will be sent to IC using the new web-enabled TMS software. IC will respond to the request within 6 hours. In the event of no response from IC for 6 hours, the request will be considered as approved. The same web application will be used by the IC/TPA for approval.

2. In case connectivity is not available at that time, pre-authorization can be requested through phone/fax also. This shall be followed by an email/ fax confirmation to the requesting hospital for

1. Hospital 2. IC

1. The same process would be valid for inter- district claims too.

2. SMS will be sent to the hospital user, as well as to the beneficiary as soon as the pre-authorization request is approved.


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recording on the TMS.

4.4 Entry of treatment details in the transaction management software

Hospital 1. No change in process 2. The entry would take

place in the new web enabled hospital software with an offline module (for business continuity plan)

Hospital Hospital will enter the details of treatment given to patient on the new transaction management software. The key new fields are:

- Signs and symptoms - Diagnosis - Diagnostics - Medications given to beneficiary (Gender of new

born in case of delivery The hospital shall be liable to enter accurate details of treatment suggested and provided to the beneficiary in the web based TMS. This will be helpful during processing of claims and any disputes arising out of it.

4.5 Transportation allowance to beneficiary at the time of discharge

Hospital 1. No change in process 2. Third party audit of 1%

sample of beneficiaries treated at hospital

3. Automated IVR call to beneficiary to validate receipt of Rs. 200 post treatment

4. In case of non-payment of Rs. 200, an SMS/email would be sent to the hospital user, based on the non-authentication by beneficiary at the hospital, confirming receipt of transport allowance.

Hospital At the time of dis-charge, hospital will pay transportation allowance to beneficiary. Also post-hospitalization medication is provided to the beneficiary for upto 5 days (as needed). The transport charges shall be part of the coverage amount of Rs. 30,000 and the beneficiary can avail a maximum of Rs. 2000 of transport allowance during a year of policy. The transport allowance shall be provided to the beneficiary in cash. The same shall be verified / audited by the 3rd party audit agency empaneled by MoLE. The beneficiary shall also validate with his finger prints at the hospital to confirm receipt of transport allowance of Rs. 200. Alternatively, he will also be given a call from the call center to confirm the same.


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4.6 Discharge of beneficiary from hospital

Hospital 1. No change in process 2. The discharge slip would

continue to be given along with SMS to the patient

3. SMS and dis-charge slip, both should clearly mention the balance card value, apart from other details of diagnostics provided and the amount charged / claimed for the same.

Hospital The beneficiary is discharged from hospital and the claim transaction is conducted by swiping the card again and authenticating the fingerprint of the patient. The hospital will not be able to send the claim to the IC unless it does not have the fingerprint authentication from the beneficiary. It is mandatory for the hospital to provide a discharge summary to the beneficiary at the time of discharge. The same shall be validated with the fingerprint of the beneficiary, call center and audit teams. The hospital must also ensure that the beneficiary RSBY card is returned to the beneficiary at the time of discharge, Any hospital found retaining the beneficiary RSBY card shall be liable for de-empanelment and fine for non-compliance.

4.7 A claim is raised by the hospital post beneficiary discharge. Currently, the hospitals do not follow a stipulated time frame for raising claims.

Hospital 1. Swiping of beneficiary card and finger print authentication of beneficiary at the time of discharge should automatically trigger the claim activity within the web based software.

2. The hospital shall complete the activity, and upload the transaction activity on the same day using the new hospital software.

Hospital In case the discharge entry is not electronically created, only the admission (blocking) entry shall not automatically raise a claim and the hospital would have to confirm treatment through any other means (Fax, email) before admitting the claim. It is also mandatory to provide the fingerprint authentication of the beneficiary to raise a claim. The hospital shall have a maximum of 7 days to raise a claim post discharge of the beneficiary.


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4.8 Maintenance of records of treatment for each beneficiary

Hospital 1. No change in process 2. The requirement to

maintain paper or electronic records needs to be reinforced. This shall be required at the time of random audits that will be initiated by the SNA / district authorities.

Hospital All diagnostic and in-patient records to be maintained by the hospital. These do not have to be submitted to the Insurance Company, but the Insurance Company or a TPA can always review and/ or ask for the copy of same at its own cost. Mole/ SNA/ District authorities will also ask for these documents through the audit agencies. Random audits shall be conducted without notice.

Policy decision taken Meeting reference

Sr. No Decisions

1 Hospitals attaining NABH entry level accreditation will automatically be empaneled as RSBY network hospitals based on their willingness

Empowered Committee Meeting of 23rd January 2014

2 IC will have to empanel at least 2 hospitals in each block of the district and one hospital per 8000 enrolled beneficiary families


3 The empanelment of hospitals will take place with the consent of SNA only. If the SNA does not respond within 5 days of the intimation from IC, approval would have been deemed to be issued.


Policy decision to be taken


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Sr. No Decisions

1 Transportation charges to be increased from Rs. 100 to Rs. 200 with a limit of 10 visits in a year. The decision to take this for approval of the Cabinet will be taken in the EC meeting on 15th May 2014.

2 Initiation of new web-based hospital management software (with offline module), which would connect with the central server

3 Capturing of mobile number of every beneficiary even at the time of registration at hospital, so that an SMS can be sent to beneficiary for every transaction (registration, pre-authorization, procedure and amount blocking, discharge)

4 Updation and revision of package rates for procedures to address the cost inflation and rationality of procedures. This should also include addition of procedures beyond INR 30,000. The decision to adopt package rates (i.e. CGHS or any other) will be taken in the EC meeting on 15th May 2014.

Incentive Mechanism

1 Not applicable


1 Training on handling hospital transaction management software and general hardware troubleshooting

Hospital Staff IC under supervision of SNA / DKM / ADKM

2

Training of hospital staff on procedures such as return of beneficiary card, biometric authentication at the time of registration, discharge, discharge slip provision to the beneficiary and return of RSBY card post discharge

Hospital staff IC under the supervision of SNA/ DKM / ADKM


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1 Monitoring and evaluation personnel to closely monitor the progress of wellness checks being conducted, and premium payment process, including management of related audit processes

At SNA, i.e. one for every state

Input for RFP/FRS RFP/FRS

1 Guideline for empanelment of hospitals RFP for empanelment of IC

2 Package lists for hospitals (this needs to be consulted and prepared by a doctor) RFP for empanelment of IC

3 Pensioners can be engaged at hospitals to support the hospital operations and assist the beneficiaries in the wellness checks conducted at PHFs / hospitals

RFP for empanelment of IC

IEC Activities

1 Display the benefits of RSBY scheme at every hospital through a display board along with basic information on procedures available at hospital.

2 Helpdesk at every hospital to facilitate the beneficiaries.


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P

roce

ss

Co

de

VI – CLM Process Name Claims Settlement (including inter-district claims)

Process Objective Current Status 1. To ensure settlement of claims within mutually agreed timelines with least

number of disputes 2. To ensure that resident is not denied service or has to face inconvenience due

to delays in claim settlement 3. To ensure a system to reduce number of fraud claims

1. Hospitals send claim requests to IC/TPA electronically through

Transaction Management Software at the hospitals

Key Stakeholders Measures and Key Performance Indices (KPIs) 1. IC/TPA

2. Hospitals

3. SNA

4. MoLE

5. Grievance Committees (DGRC, SGRC and NGRC)

Measures12: MoLE, SNA, DKM, IC/TPA, Hospital (relevant reports to be available, depending on role) 1. Number and amount of claims raised by hospitals, and

number/amount/% settled by IC Filters: Hospital type (Private, Public), Time Duration (from-to)

2. Number and amount of claims settled by, and rejected by IC Filters: Hospital type (Private, Public), Time Duration (from-to)

3. List of outstanding claim as on date Filters: Hospital type (Private, Public), Date of claim request

KPI13: MoLE, SNA, DKM, IC/TPA, Hospital (relevant KPI’s to be measured, depending on role) 1. % of claims settled, % of claims rejected –these are w.r.t. total


13

All KPI’s to be available as a report on a web portal in real-time/near-real-time. The data should be available in a warehouse, such that any extraction is possible to create ad-hoc reports.


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claim requests made 2. Average time taken to settle a claim from the time of claim

request 3. Average time taken to pre-authorize a transaction for undefined

packages 4. Average time taken to give finger-print override code for

business continuity 5. % of cases where fingerprint override was needed 6. % of cases audited by IC 7. Average time taken to submit the claims from the time of

discharge of beneficiary

Current Challenges Summary of key suggestions 1. Claim settlement is delayed by the IC, resulting in demotivation of the hospital

to serve beneficiaries 2. Fraudulent claims settled, resulting in loss to MoLE, dissatisfaction to

beneficiary and a bad reputation of the RSBY scheme 3. Claims are being rejected on flimsy grounds such as:

- Delay in claim request by hospital - Paper requirements from hospital by IC - URN number not found in IC database - Chip serial number not matching

Indicative claim rejection reasons are provided in Annexure 6.1 4. Claims are not reconciled - claims appearing in hospital books as outstanding

are appearing as settled in IC books 5. Lack of information visibility on claim settlement and claim status has resulted

in many un-reconciled claims, discouraging hospitals to join RSBY scheme 6. Lack of adherence to claim settlement SLA of 30 days by IC’s

1. Claim settlement, including claim request, payment and payment detail management, should be completely online

2. Medical audit to check fraudulent claims in a systematic manner with random sampling and in case of exception triggers from data

3. Well defined claim rejection guideline with rejection codes to be used in the application. Indicative list of rejection codes are given in Annexure 6.1

4. Upfront alerts related to ‘not covered condition’ at package blocking to minimize claim rejections due to exclusion/administrative reasons

5. In case rejected claims are invoked, it should be through reason codes selected from a drop down of pre-defined reason codes. Indicative list of rejection codes are given in Annexure 6.2

Pre-requisites for the process 1. RSBY services have been availed by beneficiary and the beneficiary has been discharged with his RSBY card

Inputs to the revised process Output from the revised process 1. RSBY beneficiaries avails cashless medical services at empaneled hospital

1. Hospitals receive timely payment from IC and system is updated

with the payment record


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Current activities Responsibility Proposed Activities Responsibilities Remarks

1 Pre-authorization for undefined packages

1.1 Pre-authorization request for treatment which is not a part of approved package list (email / fax approval by IC)

1. Hospital 2. IC

1. If the treatment required is not part of approved package list, request for pre-authorization will be sent to IC using the new web-enabled TMS software/fax/email with auto-sync.

2. IC will respond to the request within 6 hours of pre-authorization request. In the event of no response from IC for 6 hours, the request will be deemed approved.

3. The same web application will be used by the IC/TPA for approval with auto-sync feature.

3. Hospital 4. IC

1. The same process would be valid for inter- district claims too.

2. SMS will be sent to IC/TPA and to the beneficiary as soon as pre-authorization request is made.

3. SMS will be sent to the hospital user, as well as to the beneficiary as soon as the pre-authorization request is approved.

4. The new web TMS software would also have a field to capture the pre-authorization approval amount.

2 Claim Request and Settlement

2.1 Hospital raises claims using TMS

Hospital 1. The new web TMS application would be accessible by the hospital, IC, SNA/State and central user.

2. Hospital raises claims using new web TMS (with auto-sync) automatically on patient discharge (single process of discharge and claim request), which would be connected to the central server.

Hospital 1. In case they are unable to raise the claims due to HW/SW related issues, it should be intimated to IC/SNA through phone/email.

2. The electronic claim request should be triggered as soon as connectivity is available.

3. The claim request files, which the IC’s can download, should have standard format which should be well communicated with insurance


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3. Hospital should raise claims, preferably on the day of discharge itself, and latest within 7 days of discharge, in case the two processes are done separately.

companies.

2.2 Verification/validation of claims

IC/TPA 1. No change of process 2. Data should go from the new

web TMS.

IC/TPA The hospital will upload all files/ documentation while raising claims.

2.3 Field verification/audit of case, if required

IC 1. No Change. The medical audit would continue to be done by IC.

2. The IC would ensure that all the cases which are medically audited by them are flagged, and the electronic details are available with the claim record.

IC 1. Field verification, if required should be done by a qualified person (at least an MBBS degree)

2. The audit data fields should be a part of RFP floated by RSBY for IC selection.

2.4 Approval of claim IC 1. The IC would download the claim request data from the new web-enabled TMS.

2. Claim should be approved on respective claim software of IC.

IC

2.6 Payment to hospital IC 1. Payment should be made electronically, directly into the accounts of hospital(s)

2. After every payment a report giving details of payment should be generated and made available on web application. The report shall be emailed to

IC 1. SMS/email alert is sent to hospital for accepting/rejecting the part payment

2. The bank details of all hospitals should be available with all IC’s on the new web-enabled TMS. It should be captured at the time of registering the hospital.


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hospital also 3. The TDS should be a separate

‘head’ in the claim payment file

2.7 Update of claim payment in claim management application

IC 1. Every claim payment should be updated in new web-based TMS by the IC. Hospital will access the details in new web based TMS, and electronically acknowledge that the payment is made.

2. Hospitals will have to acknowledge that the claim payment has been made within 5 working days after receipt of payment in their account. The record would also indicate the details of claim approval data/time.

IC Hospital

1. An SMS would go to the hospital user on his/her mobile number indicating that “Payment of XXX.00 has been made with reference number YYYY has been made to the bank account xxxx1845. Please acknowledge receipt on the web application”.

2. A reminder SMS would go to the hospital user after 3 working days for payment acknowledgement.

2.8 No provision for claims on hold for want of further information

1. IC can put a claim under hold, after asking for more information if required, instead of rejecting it altogether, this is particularly required for public hospitals.

As of now insurance company are directly rejecting a claim on technical ground, and government hospitals are not following up even if the rejection is on technical ground. Keeping a claim on hold will provide a status to hospital and health department for close monitoring and follow up with IC.

The SNA and district committees will monitor such claims that have been put on hold by the IC.


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2.9 Appeal against claim rejected/partly paid

Hospital 1. There should be no case of part payment

2. The hospital would complain using one of the existing grievance redressal channels

Hospital 1. All grievances will be tracked in CGRMS

2. Please refer to process document on grievance redressal

2.10 No penalty for delayed settlement of claims

A Penalty of 1% of claimed amount per 15 days of delay in settlement to be paid by IC to hospital.

IC


Sr. No Decisions

1 In case claim ratio (Claim Settled + Card issuance cost)/Total premium receipt is less than 70%, IC will refund the balance amount to SNA, SNA in turn will refund the central share to MoLE

EC meeting dated 23rd January 2014

2 In case of delayed claim settlement a Penalty of 1% of claimed amount per 15 days of delay in settlement to be paid by IC to hospital

EC meeting dated 23rd January 2014

2 A clear guideline for processing of claims specifying admissible and non-admissible charges and minimizing scope of discretion shall be developed

Meeting of state sub committees with Secretary (L&E) on 9th April 2014

3 Set of agencies will be empaneled by MoLE, and SNA will hire one of them to conduct medical audit

Meeting of state sub committees with Secretary (L&E) on 9th April 2014

4 Part payment of claims should not be allowed, as it increases the chances of misuse by hospital/IC

Agreed in meeting with states under Secretary (L&E) on 06.05.2014, MoM yet to be processed in file

5 Performance levels of IC w.r.t. pending claims and rejected claims, if they fall below a certain threshold, should automatically go to the SNA as well as to the MD or senior business official of

Agreed in meeting with states under Secretary (L&E) on 06.05.2014, MoM yet to


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Sr. No Decisions

the IC (preferably the representative of IC in NGRC and/or SGRC) be processed in file

6 Rejection codes to be applied in the new TMS so that all rejected claims can be analyzed systematically for root cause. No claim should be rejected without a rejection code and a remark in the system. List of codes are listed in Annexure ??

Agreed in meeting with states under Secretary (L&E) on 06.05.2014, MoM yet to be processed in file


Sr. No Decisions

1 Development of the new web-based TMS (along with other components in the web based RSBY IT architecture) for the revised RSBY regime should be initiated by July 15. The identification of agency for development, deployment and maintenance should happen by June 30.

Incentive Mechanism

1 Not applicable


1 Facilities available under RSBY scheme and training of the proposed application (new web enabled TMS)

Hospitals (Help Desk Staff) IC

2 Training to IC on new TMS file format for claim data files so that they can integrate with their systems accordingly. This should include file structure details with additional fields on ‘medical audit’,

IC’s IT team RSBY central team for new web TMS development / IT application agency


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‘rejection codes’ and ‘TDS heads’

3 Claim rejection code training Hospital users RSBY central team for new web TMS

development / IT application agency


1 Not applicable Not applicable


1 Guideline for processing of claims specifying admissible and non-admissible charges and minimizing scope of discretion shall be developed

RFP for empanelment of IC

2 Provision of medical audit with random sampling using the new web based TMS system

1. RFP for empanelment of IC

2. FRS for selection of IT agency developing the new web-based TMS

3

(i) Audit fields for electronic claim record

(ii) Claim rejection codes

(iii) The requirement to have a separate TDS head in the claim settlement/payment data file

(iv) Calculation of penalty in case of delayed settlement of claim

1. RFP for empanelment of IC

2. FRS for selection of IT agency developing the new web-based TMS


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IEC Activities

1 Facilities available under RSBY activities and formalities to be completed to avail these services should be displayed in every empaneled hospital

2 Toll free number for making complaints should be available in every hospital in English and local language. The IEC material templates (for posters, etc.) should be designed centrally at MoLE, and should be provided to SNA for customization and further sharing with IC and hospitals

3 Poster at hospital to include that the RSBY beneficiary should insist on getting a statement in writing citing reasons as to why he/she is denied service at a hospital


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Pro

ce

ss

Co

de

VII–CGRMS

Process Name Complaint and Grievance Redressal Management System

Process Objective Current Status 1. To ensure a strong mechanism for redressal of complaints /

grievances for indirectly making the RSBY service delivery to beneficiaries more efficient

2. To provide adequate channels through which complaints / grievances can be registered, acknowledged, monitored and resolved at various levels

1. An online Central Grievance Redressal and Management System (CGRMS) is available for capturing grievances online as well as through fax/ email / phone

2. The complaint can be tracked through the online CGRMS portal using the Unique Complaint Number (UCN)

3. CGRMS does not have a provision for complaint / grievance registration through the call center and acknowledgement by SMS throughout the lifecycle till closure.

4. Grievance redressal committees have been set up at three levels: - District Grievance Redressal Committee (DGRC) - State Grievance Redressal Committee (SGRC) - National Grievance Redressal Committee (NGRC)

5. Very low usage of the CGRMS is observed (e.g. 39 grievances captured in Karnataka in 1 year)

Key Stakeholders Measures and Key Performance Indices (KPIs) 1. Beneficiary 2. Ministry of Labor and Employment (MoLE) 3. State Nodal Agency (SNA) 4. District Key Manager (DKM) 5. Field Key Officer (FKO) 6. Call Center managing GMS, inbound/outbound-calls, email, web,

SMS, post channels 7. District Grievance Redressal Committee (DGRC) 8. State Grievance Redressal Committee (SGRC) 9. National Grievance Redressal Committee (NGRC) 10. Insurance Company (IC) / Third Party Administrator (TPA) 11. Public Health Facility (PHF) 12. Hospital

Measures14: MoLE, SNA, DKM, FKO, PHF, Hospital, IC/TPA (relevant reports to be available, depending on role)

1. Number of complaints received Filters: User Category (Beneficiary, SNA, DKM, FKO, PHF, Hospital, IC/ TPA), Geography, Mode (Phone/ Call center, Email, Fax, Kiosk, post), Type, Estimated Resolution date

2. Number of complaints resolved

Filters: User Category, Mode, Geography, Time taken for Resolution, Mode of Acknowledgement (phone/call center, email, fax, Kiosk, post), Acknowledgement of Closure by Complainant (mode of closure – phone/call center, email, fax, SMS, Kiosk, post)

14

All measures to be available as a report on a web portal in real-time/near-real-time. The data should be available in a warehouse, such that any extraction is possible to create ad-hoc reports


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13. Smart Card Service Provider (SCSP) 14. Civil society

3. Number of complaints converted to grievances

Filters: User Category, Time Duration, Geography, Type, Referred to (DGRC/SGRC/NGRC),

4. Number of grievances closed Filters: User Category, Time Duration, Geography, Closed By (DGRC/SGRC/NGRC), Variance from Estimated Time, Mode Adopted for taking acknowledgement (phone/call center, email, fax, Kiosk, post), Acknowledgement of Closure by Complainant (mode of closure – phone/call center, email, fax, SMS, Kiosk, post)

KPI15: MoLE, SNA, FKO, DGRC, SGRC, NGRC, PHF, Hospital, IC/TPA (relevant KPI’s to be measured depending on role)

1. Number of complaints received against each user category

2. Number of complaints where user has acknowledged closure 3. Number of complaints resolved at District/ State/ National level

within stipulated time 4. Number of complaints converted to grievances 5. Number of complaints where appeal has been made to Committees 6. Number of complaints/ grievances with non-compliance to decisions 7. Number of complaints / grievances with compliance to decisions

within the stipulated time

Summary of current challenges Summary of key suggestions 1. Lack of awareness of grievance redressal system amongst

beneficiaries and other stakeholders leading to low usage of 1. Integration of Complaint and Grievance Management System (CGMS) with

national call center and SMS gateway; pre-printing of toll-free call center

15



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CGRMS 2. Maturity of the grievance system (e.g. appropriateness of

channel, time mapping of open grievances, SLA’s for grievance redressal etc.) is low

3. Lack of adequate training to grievance committee members on addressing and streamlining the closure of grievances

4. Lack of adequate channels for registering complaints / grievances into the CGRMS – no integration with the call center which should be the most common channel

5. No acknowledgement/feedback to/from beneficiaries - no integration with SMS gateway

6. Non-compliance by IC, hospitals etc. to decisions made by grievance committees

7. No mechanism for district and state level grievance committee proceedings to be made available to NGRC

number on the beneficiary RSBY card /cover for registering grievances 2. Call centre support would be in all local language (Asamiya, Bangla, Gujarati,

Kannada, Kashmiri, Konkani, Malayalam, Marathi, Nepali, Oriya, Panjabi, Sanskrit, Tamil, Telugu, Urdu)

3. State initiatives related to call center to continue till such time national call center is in place. However the general guidelines are valid for any interim state call center also.

4. The confirmation to close the compliant will be done by the complainant. The call center would contact the beneficiary / aggrieved party to confirm closure (through any channel)

5. Open complaints will turn into grievances after a stipulated time period depending on the type of complaint

6. Automated grievance registration, notification (SMS/email) to concerned authority/organization once grievance has been entered for redressal by his office

7. Induce SLA’s to monitor grievances and redressal mechanism 8. Grievance redressal trainings for members of grievance committee at state

and district 9. Grievance Redressal training to kiosk operators at district / block for

registering grievances of beneficiaries on CGRMS 10. Conduct training of hospital staff and insurance company to register

grievances on CGRMS, and update status of resolved grievances which were registered against them

11. Incorporate MIS reporting for monitoring SLA for complaint / grievance resolution

12. Penalty for non- compliance by IC, hospitals etc. to decisions made by grievance committees

Pre-requisites for the grievance management process 1. Integration of CGRMS with SMS gateway and call center 2. MIS reports built into the CGMS for reporting 3. Training of DGRC/ SGRC/NGRC officials on grievance redressal 4. Training of hospital staff, IC and kiosk operator on CGRMS for grievance entry and complaint/ grievance resolution process

Inputs to the revised process Output from the revised process 1. Complaint / grievance Registration

1. Resolution of complaint grievance within the stipulated time 2. Feedback on closure from beneficiary


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1 Constitution of Grievance Committees at District / State / Centre

1.1 A National Grievance Redressal Committee (NGRC) is constituted at the national Level.

MoLE 1. No change to NGRC structure

1. MoLE

2. IC

1. Annexure 7.1 provides details on the composition of NGRC

1.2 A State Grievance Redressal Committee (SGRC) is constituted at the state level within 15 days of signing of MoU with the central government.

SNA 1. No change to SGRC structure

2. MD / CEO of IC or his representative who is a decision making authority on behalf of IC should be included in SGRC.

3. MD/ CEO of IC or his representative who is included in SGRC should be included on a rotational basis.

1. SNA

2. IC

1. Annexure 7.1 provides details on the composition of SGRC.

2. The State Grievance Redressal Nodal Officer (SGRO) should be trained on CGRMS for electronic monitoring and closure of grievances.

3. The field audit reports with comments of SGRC should reach the NGRC within 3 days of conducting the audit. This shall be uploaded on the CGRMS for access by NGRC.

1.3 A District Grievance Redressal Committee is constituted at District level within 15 days of signing of MoU with IC.

SNA 1. No change to DGRC structure

2. A decision making authority from IC is to be made part of DGRC. IC should also ensure that the TPA does not represent the IC in the DGRC meetings.

SNA 1. Annexure 7.1 provides details on the composition of DGRC

2. District Grievance Redressal Nodal Officer (DGRO) should be trained on CGRMS for electronic monitoring and


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closure of grievances.

2 Set up of investigative teams

2.1 Investigative teams set up at national level are to be nominated by MoLE along with NGRC.

The investigative teams will submit their report within 15 days of the grievance / complaint being handed over to them for investigation.

MoLE No change in process MoLE 1. Annexure 7.2 provides details on the composition of investigation teams at national level.

2. Depending on the nature of grievance, NGRC can nominate any other person of technical, legal, actuarial and any other experience on a case by case basis. This person shall have atleast 10 years of relevant experience.

2.2 No investigative teams set up at state level.

Set up investigative teams at State level as indicated in Annexure 7.2.

SNA Investigative teams to be set up / nominated by SGRC.

3 Allotment of National Toll-free number

3.1 State call centers exist in some states.

IC MoLE to apply for National Toll-free number to Department of Telecom (DoT).

MoLE has applied to DoT for allotment of four digit National Toll-free number.


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4 Set up Call Centre for Grievance Redressal

4.1 Set up state level call centers for complaint / grievance registration on the CGRMS.

IC 1. The states should continue using their respective call centers in parallel to initiatives to set up the national call center. Eventually, depending on state convenience and readiness of national call center, they may phase out the state call centers.

2. The national call center for FY 14-15 should be made functional 15 days prior to commencement of enrolment process.

1. SNA (for state call center)

2. MoLE (for national call center)

1. Calls from national call center will be diverted to corresponding operator based on the selection of language done by the beneficiary.

2. The minimum number of call center seats (in every shift) for every state should be 5. This may be increased as the scheme progresses and there is better visibility on call volumes.

4.2 Set up national level call center and integrate with CGRMS.

MoLE 1. Selection of 3rd party for setting up call center at MoLE.

2. Define processes for call triaging in the call center as the call center will be run by a 3rd Party agency.

3. The services should be available 24/7 in three shifts (8 am – 4 pm, 4 pm to 12 midnight, and 12 midnight to 8m). The all night shift may have lesser number of operators depending on demand.

MoLE 1. Create list of support representatives, with contact information, for all the stakeholders so that calls can be easily triaged.

2. The minimum number of call center employees at national level should be minimum 5 for every state. This may be increased as the scheme progresses and there is better visibility on call volumes.


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4. The services offered from call center operators operating CGMS would include CGRMS data updates, auto SMS triggers, inbound calls, outbound calls, email management. All call center operators would have login into CGRMS.

5. There would be two levels of agents at the call center – operators and supervisors. The call would be diverted to a supervisor in case the request is made by the caller.

6. All calls will be recorded, and audio files will be available for audit and quality check.

- The national call center would provide the following other services besides complaint and grievance redressal:

- Information/Advice/FAQ - Directory Services

4.3 The state call centers are not integrated with CGRMS.

IC NIC can outsource the call center function to a selected third party and this call center will have to be integrated with the CGRMS. While the national call center would be integrated with CGRMS, the API’s would be made available for integration with state call centers (for interim operations at state).

1. NIC

2. Call Center Agency

CGRMS needs to be integrated with state and national call centers for complaint / grievance redressal.


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4.4 Conduct training of employees at national and state call center on the RSBY domain, applications and resolution processes.

3. MoLE


5. SNA

Employees of the national call center shall be trained on the process of handling, triaging calls and addressing complaints / grievances over the phone.

5 Conduct awareness to beneficiaries and training activities on call center and CGMS to DGRC / SGRC / NGRC / Hospital Officials / IC/ SCSP

5.1 Awareness activities on call center, email, post and CGRMS to the beneficiaries

1. Educate the beneficiary on call center, email, post and other complaint channels through print media/ audio media / electronic media / television / FKO / SNA / IC and other government communication channels such as broadcast media.

2. Printing of National Toll Free number on the RSBY card and card cover, and RSBY brochure.

3. Village walls to be painted with toll-free number

4. National call center number to be

1. MoLE/SNA / FKO / IC

2. SCSP

3. SNA / DKM

1. The beneficiary needs to be made aware of the call center facilities and the kind of complaints he/she can register or get resolutions for.

2. A probable/ indicative list of complaints / grievances exhibited in Annexure 7.3. This list can be elaborated based on the nature of complaints that are received over the period of RSBY operations.


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printed on every IEC material

6 Complaint registration mechanism for beneficiary, and resolution at Hospital/IC/FKO level

6.1 Beneficiary registers his grievance using one of the limited existing channels

- Post - Email - Web - kiosk

Beneficiary 1. Register complaint through one of the following: national toll-free call center, email, post, SMS, web (CGRMS) and kiosk

2. Once the complaint is received, a detailed log is entered into the CGRMS system by the operator of the call center agency

3. An SMS/email would be sent to the beneficiary with the service request number and time for resolution of the complaint. The SMS would go in two languages (English and local).

4. If the complaint is against a specific hospital/IC/FKO, the record will be made available to the relevant stakeholder.

5. The beneficiary can reach out to the call center or any other channels again, to check the status of service request by indicating the request number.

Beneficiary The beneficiary can check the status of the complaint through the web, email and kiosk by providing the service request number.


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6.2 No well-defined process for complaint resolution

IC / hospital / FKO

1. The Hospital/IC/FKO acts upon the registered complaint for resolution at their end.

2. Once the complaint is resolved at their end, they will update the CGRMS through one of the channels, against the service request number. The tentative closure of the complaint would be available in CGRMS.

3. The call center operator would call the beneficiary to verify whether the complaint has been resolved. If the call is not taken, the call center operator would try two more times within 24 hours.

4. Once verified, the call center operator would ‘close’ the complaint. An SMS would go to the beneficiary and corresponding IC/Hospital/FKO about the closure. The complaint would be deemed closed if the beneficiary is not able to take any of the 3 calls.

5. If the beneficiary still has a complaint, the status would be reversed to ‘open’, and the hospital/IC/FKO would receive

1. IC

2. Hospital

3. Beneficiary

4. FKO

5. Call center Agency

After the stipulated period of 15 days, the complaint, if still unresolved, would turn into a grievance.


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an SMS/email notification

6.3 Grievances once entered into the system are taken up for resolution by DGRC/ SGRC/NGRC / DGLW as per priority and escalation levels.

DGRC / SGRC / NGRC / MoLE

The CGRMS shall provide for auto assignment of grievances to respective grievance committees through automated CGRMS if the complaint is not resolved within the stipulated timeline.

6. DGRC / SGRC / NGRC / MoLE

1. A daily summary SMS/email notification will be sent to the respective grievance redressal committees for grievances that have been referred to their office.

2. DGRC shall receive a grievance if the complaint is not resolved within 15 days.

6.4 District and state level grievance committees do not update the decisions of their meetings / decisions to NGRC.

DGRC/SGRC DGRC / SGRC shall update the proceedings / decisions of their meetings on CGRMS for further reference by NGRC.

DGRC / SGRC This will serve as crucial information for MIS generation and history of a grievance in the event of escalation of a grievance at the central level (NGRC).

7 Complaint registration mechanism for hospitals, and resolution at IC level

7.1 Hospital submits its complaint in writing to DGRC.

Hospital/ PHF 1. Register complaint through one of the following: national toll-free call center, email, post, SMS, web (CGMS), kiosk.

2. Once the complaint is received, the call center operator updates the complaint log in CGRMS system.

3. An SMS/email would be sent to

1. Hospital / PHF


1. This would be possible after CGMS has been modified with a ticket based system. The hospital should be provided with a username and password to the CGRMS for entering its complaint or monitoring the status.

2. Awareness about CGRMS and


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hospital user with the service request number. The SMS would go in two languages (English and local).

4. If the complaint is against a specific IC, the record will be made available to the IC, DGRO as well as to DKM and SNA.

5. The hospital can check the status of the service request through the call center or any other channels (web, kiosk).

the call center would need to be carried out round the year to encourage its usage.


1. The IC acts upon the registered complaint registered for resolution at their end.

2. Once they have resolved the complaint at their end, they shall update the CGRMS through one of the channels, against the service request number. The tentative closure of the complaint would be available in CGRMS.

3. The call center operator would call the hospital to verify whether the complaint has been resolved. If the call is not taken, the call center operator would try and additional two more times within 24 hours.

1. IC / SCSP

2. Hospital / PHF


The hospital / PHF can check the status of the complaint through the web, email and kiosk by providing the service request number.


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4. Once verified, the call center operator would ‘close’ the complaint. An SMS would go to the hospital and IC about the closure. The complaint would be deemed closed if the hospital user is not able to take any of the 3 calls.

5. If the hospital still has the complaint, the status would be reversed to ‘open’, and the IC would receive an SMS/email notification.

8 Complaint registration mechanism for IC, and resolution at hospital level

8.1 IC submits its complaint in writing to DGRC.

IC / SCSP 1. Register complaint through one of the following: national toll-free call center, email, post, SMS, web (CGMS), kiosk.

2. Once the complaint is received, the call center operator updates the complaint log in CGRMS system.

3. An SMS/email would go the IC/SCSP user with the service request number. The SMS would go in two languages (English and local).

4. If the complaint is against a specific hospital and/or beneficiary, the

1. IC/ SCSP


1. This would be possible after CGRMS has been modified with a ticket based system and integrated with the proposed web based application.

2. The IC / SCSP should be provided with a username and password to the CGMS for entering its grievance.

3. SNA would create authorized IC users in CGRMS.

4. IC would create authorized SCSP users in CGRMS.


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record will be made available to the hospital and/or beneficiary, DGRO as well as to DKM and SNA.

5. If the complaint is against SNA, the record will be made available to the SNA and to NGRO.

6. The IC / SCSP can check the status of the service request through the call center or any other channels (web, kiosk).


1. The hospital acts upon the complaint to resolve it at their end.

2. Once they have resolved the complaint at their end, they will update the CGRMS through one of the channels, against the service request number. The tentative closure of the complaint would be available in CGRMS.

3. The call center operator would call the IC to verify whether the complaint has been resolved. If the call is not taken, the call center operator would try two more times within 24 hours.

4. Once verified, the call center operator would ‘close’ the complaint. An SMS would be sent to

1. Hospital / PHF

2. IC/ SCSP


If the IC still has a complaint, the status would be reversed to ‘open’, and the hospital would receive an SMS/email notification.


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the hospital and IC about the closure. The complaint would be deemed closed if the IC user is not able to take any of the 3 calls.

9 Grievance registration mechanism for SNA

9.1 SNA submits in writing to SGRC / NGRC.

SNA 1. SNA registers the complaint through web (CGRMS), post, call center.

2. Once the complaint is received, a complaint log is entered into the CGRMS system by the operator of the agency operating the call center.

3. If the complaint comes by post to NGRC, NGRO would digitize the complaint and upload the details on CGRMS.

4. An SMS/email would be sent to the SNA user with the service request number. The SMS would go in two languages (English and local)

5. If the complaint is against a specific hospital and/or IC, the record will be made available to the hospital and/or IC, with a notification to

SNA 1. This would be possible after CGRMS has been modified with a ticket based system and integrated with the proposed web based application.

2. The SNA should be provided with a username and password to the CGRMS for entering its grievance.


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NGRO.

10 Grievance Redressal Mechanism – Beneficiary (once complaint turns into grievance)

10.1 1. The beneficiary approaches DGRC with a grievance against FKO, IC, hospital or their representatives.

2. DGRC should take a decision within 30 days of receiving the complaint.

1. Beneficiary

2. DGRC

1. In CGRMS, the complaint is visible as grievance after 15 days (stipulated timeline). This complaint will automatically be assigned to the DGRC office along with an SMS and email to the beneficiary and DGRO.

2. The grievance is shown in DGRO inbox for resolution. DGRC shall investigate and provide a resolution of the grievance / compliant on the CGMS after the DGRC meeting.

3. The beneficiary will get a registered mobile call verifying the resolution, once DGRC has updated the same on CGRMS. If the beneficiary does not provide a response after three tries the resolution is deemed accepted.

4. If the beneficiary does not verify on the registered mobile (indicating the resolution has not happened as per his satisfaction), he/she would be given an option on call to

1. Beneficiary

2. DGRO

3. SGRO


1. The escalation from DGRC to SGRC would happen automatically if the issue is not resolved within 30 days. However, if the issue is resolved at DGRC, and the beneficiary is not satisfied, the escalation can take place before 30 days after consent from beneficiary.

2. If DGRC decision is not complied by IC/Hospital or any other stakeholder, it is in the interest of DGRO to ensure compliance before closure of the request in CGRMS. Else, it would result in escalation to SGRC after consent from beneficiary.

3. The IC/hospital against which the original complaint was made by the beneficiary would indicate compliance in the system after DGRC decision. The DGRO would ensure


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escalate to SGRC. In case the answer is yes, the same electronic grievance request would go to SGRC inbox and a same process of redressal would follow.

compliance through the system. The DGRO may go ahead and update the issue as closed, but the responsibility of ensuring compliance would be that of DGRO.

4. There would be an option to verify the closure of grievance using email also. The email would be sent by contact center operator.

11 Grievance Redressal Mechanism – Hospital (once complaint turns into grievance)

11.1 1. If the hospital has any grievance with respect to beneficiary, IC, or their representatives, state government officials etc. It will approach the respective redressal committee, and can go another level up in case the grievance is not redressed.

2. DGRC / SGRC / NGRC should take a decision within 30 days of receiving the complaint. Only one appeal is allowed.

1. Hospital

2. DGRC/ SGRC /

1. In CGRMS, the complaint is visible as a grievance after 15 days (stipulated timeline). This complaint will automatically be assigned to the DGRC office along with an SMS and email to the hospital user and DGRO.


3. The hospital will get a registered mobile call verifying the resolution, once DGRO has updated the same

1. Hospital

2. DGRO

3. SGRO

4. NGRO


1. The escalation from DGRC to SGRC (and subsequently to NGRC) would happen automatically if the issue is not resolved within 30 days. However, if the issue is resolved at DGRC end, and the hospital is not satisfied, the escalation can happen before 30 days after consent from hospital.

2. If DGRC decision is not complied by IC or any other stakeholder, it is in the interest of DGRO to ensure compliance before closure of the request in


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NGRC

on CGMS. The resolution shall be deemed accepted if the hospital user does not respond to 3 calls.

4. If the hospital does not verify on registered mobile (indicating the resolution has not happened as per his satisfaction), he/she would be given an option on call to escalate to SGRC. In case the answer is yes, the same electronic grievance request would go to SGRC inbox and a same process of redressal would follow.

5. If the resolution does not happen even at SGRC level, the hospital would have the same choice to escalate to NGRC.

CGMS. Else, it would result in escalation to SGRC after consent from hospital.

3. The IC or any other stakeholder against whom the original complaint was made by the hospital would indicate compliance in the system after DGRC decision. The DGRO would ensure compliance through the system. The DGRO may go ahead and update the issue as closed, but the responsibility of ensuring compliance would be of DGRO.

4. The three points above are valid for further escalation from SGRC to NGRC as well.

5. There would be an option to verify the closure of grievance using email also. The email would be sent by call center operator.

12 Grievance Redressal Mechanism – Insurance Company (once complaint turns into grievance)

12.1 1. If the IC has any grievance with respect to beneficiary, hospital, state government

1. Hospital

2. DGRC/SG

1. In CGRMS, the complaint is visible as a grievance after 15 days (stipulated timeline). This complaint

1. IC 1. The escalation from DGRC to SGRC (and subsequently to NGRC) would happen


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officials etc. It will approach the respective redressal committee, and can go a level up in case the grievance is not redressed.

2. DGRC / SGRC / NGRC should be able take a decision within 30 days of receiving the complaint. One appeal is allowed.

RC/NGRC

will automatically be assigned to the DGRC office along with an SMS and email to hospital user and DGRO.


3. The IC shall get a call verifying the resolution, once the DGRO has updated the same on CGMS. If the IC does not provide a response after three tries the resolution is deemed accepted.

4. If the IC does not verify on registered mobile (indicating the resolution has not happened as per his satisfaction), it would be given an option on call to escalate to SGRC. In case the answer is yes, the same electronic grievance request would go to SGRC inbox and the same process of redressal would follow. If the resolution does not happen even at SGRC level, the IC would have the same choice to escalate to NGRC.

2. DGRO

3. SGRO

4. NGRO


automatically if the issue is not resolved within 30 days. However, if the issue is resolved at DGRC end, and the IC is not satisfied, the escalation can happen before 30 days also after consent from IC.

2. If the DGRC decision is not complied by hospital or any other stakeholder, it is in the interest of DGRO to ensure compliance before closure of the request in CGRMS. Else, it would result in escalation to SGRC after consent from IC.

3. The hospital or any other stakeholder against which the original complaint was made by the IC would indicate compliance in the system after DGRC decision. The DGRO would ensure compliance through the system. The DGRO may go ahead and update the issue as closed, but the responsibility of ensuring compliance would be of DGRO.

4. The three points above are valid for further escalation


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from SGRC to NGRC as well.

5. There would be an option to verify the closure of grievance using email which can be sent by the call center operator.

13 Complaint and Grievance Redressal Mechanism –for complaints/grievances to/against SNA / State Government


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13.1 1. A grievance against the action or decision of the SNA / State Government can be referred to NGRC in writing.

2. The complaint can be made by beneficiary/IC/hospital/FKO or any other stakeholder.

1. Aggrieved party

2. NGRC

1. Depending on the nature of complaint, the contact center operator would decide whether it is a complaint against SNA/state. The SNA/state user would get an email/SMS indicating a complaint. The SNA/state may act upon it and close the complaint at their end.

2. The call center operator would give a call on registered mobile number of the aggrieved party to verify resolution. The call would be tried thrice in 24 hours. If the aggrieved agrees to resolution, the complaint would be closed. However, if the party does not indicate satisfaction, the complaint would turn into a grievance and would go to NGRC, and would appear in NGRC inbox with an email/SMS to NGRO.

3. NGRC would investigate and take a decision in this regard. The NGRO, before updating the CGMS, would ensure compliance.

1. Aggrieved party

2. SNA / state Government

3. Call Centre Agency

Policy decision taken Meeting reference

Sr. No Decisions Date

1 Manual for Grievance Redressal Mechanism 18th March 2014


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2 Integration with SMS gateway of DeitY 23rd January 2014

3 National Toll-free number for beneficiaries 9th April 2014

4 The current practice of transferring a grievance from SGRC to NGRC may be continued with a limit of one appeal per beneficiary

Meeting dated 6th May 2014, chaired by Secretary (L&E), MoM yet to be processed in file

5 The meeting of SGRC is to be held every month Meeting dated 6th May 2014, chaired by Secretary (L&E), MoM yet to be processed in file

6

Hiring of additional manpower (2-3 people) to manage grievances at SNA & NGRC. The hiring of this manpower shall be dependent on the number of grievances that have been escalated to SGRC & NGRC. The role of such manpower shall be to:

a. analyze the grievances received, b. investigate past action taken before getting converted to grievances, c. bring out appropriate measures to the SGRC / NGRC for resolving these grievances; and

Ensuring compliance to the decisions of SGRC/ NGRC within the stipulated time period by various stakeholders

Meeting dated 6th May 2014, chaired by Secretary (L&E), MoM yet to be processed in file


Sr. No Decisions

1 Decision on whether to have a single location of national call center i.e. single physical location, or a distributed model where call center operators would sit out of different offices at state level

2 The end to end responsibility of development/enhancement of the overall RSBY IT platform portfolio including but not limited to (i) current GMS to a robust CGRMS with email/SMS/call-center integration (ii) central server, web application (iii) new TMS software at hospital can be outsourced to a renowned IT organization with guidance from NIC.

3 Hiring of RSBY field coordinator identified at every district level needs to be enforced, and the deadline for the same should be June 30


1 Training on handling the CGRMS application and handling complaints / grievance process

MoLE / NIC / SNA / DKM / district and state grievance committees / kiosk operators / e-entrepreneurs / e-pensioners / call center staff

IT application agency / call center agency

Input for RFP/FRS RFP / FRS

1 Setting up of Call Center to be run by 3rd Party Agency and integration of RFP / FRS


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Call Center with Grievance Management System

2 Empanelment of audit agency for CGRMS by MoLE RFP

IEC Activities

1 Awareness and education of beneficiaries / all stakeholders on CGRMS system and process for RSBY


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Pro

ce

ss

Co

de

VIII - KSK Process Name

Kiosk Management

Process Objective Current Status 1. Providing RSBY administrative services to the beneficiary upto

the block / taluka / mandal level for enhanced beneficiary access 2. Provide convenience of member addition / data updation / lost

card replacement to the RSBY beneficiary, as well as complaint or grievance registration

1. Kiosks exist only at district level 2. Centralized software for kiosks exits, which works in offline mode and

updates data once connected to the internet. The kiosk connects to the insurance company server in some cases or functions only when the post-enrolment data is available on the district server. This data is loaded on the kiosk computer, which usually is done after 2-3 months of enrolment process

3. Some of the kiosks at district level are non-functional due to lack of post enrolled data, manpower, internet connectivity or infrastructure

4. Multitasking of the kiosk operator (use of kiosk personnel for other RSBY related work in the district or by the DKMA)

Key Stakeholders Measures and Key Performance Indices (KPIs) 1. Beneficiary 2. Ministry of Labor and Employment (MoLE) 3. State Nodal Agency (SNA) 4. Insurance Company (IC) / Third Party Administrator (TPA) 5. Hospitals 6. District Key Manager (DKM) 7. Kiosk operator

Measures16: MoLE, SNA, DKM, IC/TPA, kiosk operator (relevant reports to be available, depending on role) 1. Number of kiosks made functional

Filters: User Category (SNA, DKM, SCSP, Kiosk operator), Geography (District, Taluka/ Block, Mandal etc.), Time period by which made functional17(15 days prior to enrolment process), Trained Kiosk operators

2. Number and type of transactions performed by kiosk

Filters: Transaction Type (add, update, card replacement, card splitting, complaint registration, status update to beneficiary, update of manual transactions by the hospitals), Kiosk Type (district / block), Geography, Time period of transactions, Average Time per Transaction

3. Uptime of the kiosk

16

All measures to be available as a report on a web portal in real-time/near-real-time. The data should be available in a warehouse, such that any extraction is possible to create ad-hoc reports 17

Functional kiosk means one that has functional software and hardware, trained kiosk operator and can conduct transactions, record complaints / grievances of the beneficiaries


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Filters: User Category, Geography, Start Time, End Time, Offline data upload time

4. Number of kiosks non-functional Filters: User Category (Kiosk operator), Geography, Start Time, End Time, Complaint registered (call center, Web/email), Complaint Type (hardware/ software / network failure)

5. Time to resolve non-functionality of kiosk Filters: User Category, Geography, Date of Complaint Registration, Date of Complaint Resolution, Uptime of Kiosk

KPI18: MoLE, SNA, SCSP, Kiosk Operator (relevant KPI’s to be measured depending on role) 1. Number and % of kiosks setup and made functional

2. Number and type of transactions performed by the kiosk (including

complaint and grievance registration and status update to beneficiary) 3. Average time taken per transaction type 4. Average uptime of the kiosk per day/ per month/per quarter/ per year 5. Average time taken to resolve hardware/ software/ connectivity issues at

kiosk

Summary of current challenges Summary of key suggestions 1. Non-accessibility of kiosks for the beneficiary (only at district)

leading to difficulty in accessing RSBY administrative services by beneficiary.

2. Non issuance of username and password to kiosk operator by IC. 3. District kiosks do not have timely access to post enrolment data

to provide services to RSBY beneficiaries 4. Lack of standard operating procedures at kiosks, with no SLA’s

1. Establishment of kiosks at the block level to expand reach of services for RSBY beneficiaries, which will be managed by the centrally empaneled SCSP

2. SNA shall provide the SCSP with civil and electrical work at the identified kiosk location

3. The SCSP shall provide the manpower, hardware, training and services to the beneficiaries through the kiosk

4. Additional stress on training and access of new web application as well as

18



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for performance monitoring of kiosks 5. No synchronization of pre and post enrolment data and hospital

claim data for facilitating kiosk operations 6. Low level of awareness about the utility of kiosks for different

beneficiaries 7. Lack of training to kiosk operators for efficient service delivery

CGRMS interface for kiosk operators 5. Introduction of SLA’s for electronic performance monitoring of kiosks

through the web application; audit of kiosk operations 6. The SCSP can also choose to employ e-entrepreneurs /pensioners / self-help

groups at block / district level as kiosk operators

Pre-requisites for kiosk set-up and management 1. Identification of kiosk location at district and block level; hiring of kiosk operators 2. Access to central web application and CGRMS for the kiosk operator for transactions at district /block level for delivering services to RSBY

beneficiaries 3. Access to of URN generated data, transaction data of beneficiary for the kiosk operator through the central web application

Inputs to the revised process Output from the revised process 1. Beneficiary request for addition/updation/lost card replacement

of RSBY enrolment data, or for logging a complaint 1. Delivery of administrative services to the RSBY beneficiary 2. Updated / modified enrolment data in the central server


Sr. No


1 Establishment of Kiosk

1.1 IC receives work order from SNA and it makes a request for availability of space at district and block to operationalize the kiosk.

SNA 1. The centrally empaneled SCSP makes a request to SCSP for availability of space at district and block to operationalize the kiosk.

2. SNA will ask DKM to provide options of space for kiosks at block and district at a public place which is frequented and easily accessible.

1. SNA

2. DKM

1. SNA will provide the confirmation of space for kiosks at block/ district level to SCSP with the help of DKM within 15 days of receiving the request from SCSP.

2. SCSP and DKM will confirm the requirement of civil / electric work at the space provided.

3. SNA & DKM shall ensure that


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3. SCSP will establish kiosks at district and block level.

3. SCSP basic civil and electrical work is completed at the location of kiosk for smooth operations. The SNA will bear the cost of civil & electrical infrastructure work at the identified kiosk locations.

1.2 IC procures hardware and commences installation at district kiosk.

IC The SCSP will establish kiosk at block level too. It will be required to procure hardware for both district and block level kiosks.

SCSP 1. SCSP will provide for hardware and other related infrastructure at the kiosk. The details of the hardware to be provided by SCSP at the district/ block kiosk are provided at Annexure 8.1.

2. The software will be provided by MoLE, which would a centralized web application.

1.3 IC signs the Annual Maintenance Contract (AMC) agreement for kiosk hardware and kiosk management software.

IC SCSP signs Annual Maintenance Contract (AMC) agreement for kiosk hardware and application as part of the contract agreement with SNA.

SCSP 1. The SCSP shall own the AMC for the hardware, software and related infrastructure for smooth operations.

2. The software for RSBY kiosk operations shall be maintained by the SCSP operating the kiosk with the help of MoLE / SNA. It will be the responsibility of SCSP to communicate/update the offline-module upgrades of the kiosk application.


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1.4 Installation of stand-alone (offline) module kiosk management software at kiosk.

IC No change SCSP MoLE shall provide SCSP with the stand-alone kiosk management software for installation at kiosk and provide a username and login for performing transactions.

1.5 IC performs testing of all equipment, software and connectivity at the kiosk.

IC The SCSP will perform testing of all equipment, software and connectivity at kiosk and certify the functioning of the kiosk.

SCSP The SCSP will ensure the functioning of the kiosk software and hardware and shall resolve any connectivity issues. It may obtain support of the SNA / DKM in case of major issues faced in obtaining connectivity for the kiosk.

1.6 No hoarding / information board outside the kiosk, displaying the key services provided.

IC 1. Hoarding / information board to be provided by the SCSP. Basic information to facilitate services to the beneficiary will be displayed on the hoarding/ board.

2. The guidelines and template for IEC material should be provided by MoLE, and customized by SCSP for kiosk setup. A tentative format of the display board is provided in Annexure 8.2

1. SCSP

2. MoLE

The kiosk shall display a hoarding / information board which will display the benefits of the scheme, services being provided at the kiosk along with their rates, national toll-free number, procedure for filing a complaint / grievance, updated brochures of empaneled hospitals / web list of empaneled hospitals for beneficiaries.

2 Recruitment and Training of manpower for kiosk


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2.1 IC advertises and recruits manpower for kiosk operations at district level.

IC 1. The SCSP will recruit operators for block and district kiosks. It will also train these operators and ensure that these operators are ready to conduct transactions prior to the commencement of enrolment process.

2. The SCSP will provide a record of all hired operators 15 days prior to the enrolment process so that the operator details and mobile numbers are fed into the central system to create operator records.

SCSP 1. The SCSP may consider the hiring of e-entrepreneurs, pensioners and self-help workers for manning the kiosks. This exercise must be completed prior to commencement of enrolment process.

2. The kiosk personnel should not be engaged in other activities apart from RSBY related activities and should be available at kiosk during the agreed designated hours.


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2.2 IC provides training to the kiosk operators at district level on kiosk operations and card management.

IC 1. The SCSP will provide training of kiosk operators at district / block level on kiosk operations, card management and handling the CGRMS application.

2. The training of kiosk operators to be done as per the structured training manual for RSBY kiosk operations prepared by MoLE.

3. The DKM shall closely monitor the training of kiosk operators. The successful completion of training shall be updated in the web based application by DKM.

4. The SCPSP updates the record/login for all operators in the central web application as well as in CGRMS and provides confirmation on training of operators.

1. SCSP

2. DKM

3. MoLE

Two day workshop to be conducted by SCSP with hands-on training for all operators prior to commencement of enrolment. The - training shall be provided on the following areas:

- General Kiosk operations and use of Master Kiosk Card (MKC)

- Management of card (updation / modification / card split / lost card replacement / invalid card replacement)

- CGRMS and managing complaints for entry into CGRMS

- Call center functions - Charges for each service

The SCSP can add additional areas of training as per the requirements.

2.3 No training provided to stakeholders at district level

IC 1. Training of other stakeholders from state, district and block shall be provided by the SCSP.

2. The SNA shall provide funds for training for all stakeholders.

3. DKM shall provide a sign-off on

1. SCSP

2. DKM

3. SNA

A two day workshop to be conducted by the SCSP with hands-on training for all stakeholders (SNA, DKM, FKO, DIO) prior to commencement of enrolment. The training shall be provided on:

- CGMS and managing


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the completion of training to the SCSP. This shall be updated in the web based application.

complaints for entry into CGMS

- Call center functions - Kiosk operations and card

management (DIO card, DKM card, MKC card, MHC and PHC card, FKO card)

The SCSP can add additional areas of training as per the requirements.

2.4 The kiosk operators at district are issued the Master Kiosk Card (MKC) for conducting transactions at kiosk post completion of training. The MKC card is personalized by the DKM prior to issuance to kiosk operator.

DKM 1. The DKM will personalize the MKC card which will also include the biometrics of the kiosk operator which needs to be authenticated prior to accessing the kiosk management system.

2. The MKC would be issued to every operator at the block level as well.

3. The contact numbers of block level kiosk operators should be made available to the contact center agents, through the web based system, so that the callers may be referred to them.

DKM The details of all the MKC cards issued will be stored in the web based application, for further authentication during kiosk operations.

2.5 The IC will create user name and password for the kiosk operator.

IC The SCSP will issue the username and password to the kiosk operator for logging into the kiosk interface of the web application and the stand-alone module. This will be a pre-requisite for conducting valid

SCSP 1. The SCSP will create accounts for kiosk operators through the web application for access to the kiosk software / stand-alone application.


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transactions at the kiosk. 2. The SCSP will be provided with a privilege to create kiosk operator accounts limited to the number of kiosks they will be setting up at district and block.

3. The SCSP will provide the SNA with the number and details of kiosks they will be setting up at district / block level.

3 Providing various services to RSBY beneficiary through the kiosk

3.1 The beneficiary goes to district kiosk for availing services such as updation / modification / card split / lost card replacement / invalid card replacement etc.

Kiosk operator The beneficiary will now be able to get services such as updation / modification / card split / lost card replacement / invalid card replacement from the district/ block kiosk.

Kiosk operator 1. Only existing enrolment data can be added to the replacement card. Enrolment of new family member can be done only if the slot is empty on the card.

2. Alternatively a kiosk portal can also be created, wherein the beneficiary can request for a service from his door step/PHF/hospital etc

3.2 Re-issuance of card at district

1. At the district kiosk, based on the URN, the current card serial number will be marked as hot-listed in the backend

District kiosk operator

Re-issuance of card at district / block kiosk using MKC card.

The following is process of card re-issuance:


Re-issuance of card can be done when the beneficiary card is reported lost or the card is invalid / damaged. The following is the process to be adopted by the district


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to prevent misuse of the lost/ missing/ damaged card.

2. The existing data of the beneficiary including photograph, fingerprint and transaction details shall be pulled up from the state server, verified by the beneficiary and validated using the beneficiary fingerprints.

3. The beneficiary family shall be given a date (based on SLA with state government) for collection of the re-issued card.

4. It is the responsibility of the insurance company to collate transaction details of the beneficiary family from their central server (to ensure that any transactions done in some other district are also available).

5. The re-issued card is

personalized with details of beneficiary family, transaction details and insurance details within the defined time using the Master

1. At the district kiosk, based on the URN, the current card serial number will be marked as hot-listed in the backend to prevent misuse of the lost/ missing/ damaged card.

2. The existing data of the beneficiary including photograph, fingerprint and transaction details shall be pulled up from the central server, verified by the beneficiary and validated using the beneficiary fingerprints.

3. The beneficiary family shall be given a date (based on SLA with state government) for collection of the re-issued card.

4. The transaction details shall be updated at the central server.

5. The re-issued card is personalized with details of beneficiary family, transaction details and insurance details within the defined time using the Master Kiosk Card (MKC).

6. The beneficiary pays the cost of the smart card at the district

kiosk:

The beneficiary shall pay the cost of the smart card as decided by MoLE.


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Kiosk Card (MKC).

6. The beneficiary pays the cost of the smart card at the district kiosk and collects his new card.

kiosk and collects his new card.

3.3 Card split service is offered at the district kiosk. The following is the process followed for card split:

- The fingerprints of any family member shall be verified against those available in card.

- The splitting ratio should be confirmed from the beneficiary. Only currently available amount (i.e. amount insured - amount utilized) can be split between the two cards. The insured amount currently available in the main card is modified.

- The cost of the additional smart card needs to be paid by the beneficiary at the district kiosk

- The beneficiary’s existing data, photograph, fingerprint and transaction details are fetched from the district server and a fresh card (add-on card) will be


1. No change in the process. The card split facility shall continue to be offered only from the district kiosk.

2. The beneficiary’s existing data, photograph, fingerprint and transaction details shall be fetched from the central server instead of the district server in the already existing process.


Card splitting is done at district (using MKC card) and kiosk to help the beneficiary to avail the facilities at two diverse locations i.e. when the beneficiary wishes to split the insurance amount available on the card between two cards

The points to be kept in mind while performing a card split are as follows:

1. The existing data including text details, images and transaction details shall be fetched from the central server.

2. Card split may be carried out only if there is no blocked transaction currently on the card

3. - In case a split card was issued in the interim, both cards would be required to be present at the time of modification.


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issued immediately to the beneficiary family. Both cards would have details of all family members.

- The existing card will be modified and add on card issued using the MKC card.

- Fresh and modified data shall be uploaded to the central server as well.

3.4 Card modification service is provided at district kiosk is done using the MKC card. The following is the process for modification / updation in the beneficiary card:

1. During the time of enrolment if only the head of the family was present, the details of other family members can be updated in the RSBY card at the district kiosk.

2. In the event of death of any person in beneficiary family, enrolled on the card, another family member from the beneficiary family list associated with the URN is to


1. Card modification will now be available at district / block kiosk using MKC card.

2. A new photograph of the family may be taken (if all the members are present or the beneficiary family demands it).

3. Fingerprint of additional members needs to be captured.

4. Data of family members has to be updated on the chip of the card.

5. The existing details need to be modified in the database (central server).

District / block operator

It is to be ensured that only members listed on the original category list provided by the state are enrolled on the card. As in the case of enrolment, no modifications except to age and gender may be done.


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be added to the card.

3.5 District kiosk operator provides data to IC for all online and offline transactions. IC updates this data on its server.

1. Kiosk operator

2. IC

District / block kiosk operator provides data to central server for all online and offline transactions through the web application.

Kiosk operator The kiosk operator can conduct transactions using the stand- alone software provided to him and can synchronize the data once he has connectivity. The data shall be synchronized with the central server which can be accessed with the web based application.

3.6 Card split and duplicate card issuance requires visit to district kiosk

NA 1. Beneficiary will visit nearest block kiosks to request for a split card or duplicate card

2. In case of duplicate card block kiosk will hot-list the lost card, and initiate a request for duplicate card

3. For split card, he will capture the request along with required information such as split amount, members on split card and initiate a request on the web based software

4. Beneficiary can also give his preference of a district kiosk from where he can collect the new card

Block kiosk operator

1. Block kiosk will provide all the services, which do not require use of card printer. For services which require card printer he will only initiate the request, which can be completed at district kiosks. This will reduce the hassles for beneficiaries and will reduce the load on district kiosks

2. In the case of states with high migrant population, card printers can be provisioned at the block level as well


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5. Beneficiary will be provided with a date on which he can collect his duplicate/split card from district kiosk

4 Re-issue of MKC card to the kiosk operator

4.1 In the event of loss of MKC card / card becoming invalid / broken card, the kiosk operator requests the DKM to provide him with a replacement card.

DKM 1. In the event of loss of MKC card / card becoming invalid / broken card, the kiosk operator requests for a new card either by calling the national toll-free call center number or calling the District coordinator.

2. The DKM / district coordinator will provide the kiosk operator with a replacement card within 3 days of receiving the request either through the web based application / direct request / call center request/ email.

DKM / District coordinator

1. The preferable mode for kiosk operator is to request through the call center as an SMS / email will be sent to the DKM to issue and personalize the MKC card.

2. The kiosk operator at the district/ block level is required to travel to the DKM for authentication and collection of new MKC card.

4.2 Master hospital card cannot be prepared at district level

1. MoLE will provide additional blank master hospital card to DKMA

2. In case of requirement of hospital cards, DKMA will personalize a new blank card

3. District kiosk will print name and code on the hospital card,

1. DKMA

2. Kiosk operator


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before handing it to hospital


Sr. No Decisions

1 SNA shall operate the kiosks with their manpower (i.e. e-entrepreneurs and pensioners).

9th April 2014

2 Hardware for kiosks to be procured by IC.

9th April 2014

3 Kiosk to be set up under the PPP model whereby existing CSCs can be leveraged.

9th April 2014


Sr. No Decisions

1 Decision to reverse the decision taken in the meeting held on 9th April 2014, wherein it was decided that the SNA’s would operate the kiosks with their manpower

2 In case of states with high migratory population, a provision for smart card printers at block level can be made


1 Training on handling kiosk operations through stand-alone software and web based application

Kiosk operators SCSP / IT application agency


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3 Training on handling the CGRMS and entering beneficiary grievances into the portal at kiosk.

Kiosk operators (e-entrepreneurs / pensioners)

SCSP / IT application agency

Input for RFP/FRS Inputs for:

1 Details on setting up of kiosk at district / block level

RFP for SCSP selection

2 Eligibility on minimum qualification and IT/communication skills to become a kiosk operator at district / block level


3 Maintenance of kiosks, hardware, software and related equipment for smooth functioning of kiosks


4 Central web application and CGRMS access to kiosk operators, with offline module for synchronization back with central server on all transactions (addition/update/lost-card-replacement) and complaints

FRS for IT agency

IEC Activities

1 Education of beneficiaries and hospitals and other stake holders on facilities available at kiosk

2 Continuous education / training of operators on any new functionality changes in the RSBY scheme

Incentive mechanism

1 States (SNA) can take a decision on the incentive to kiosk operator for excellent performance and service to beneficiaries


1 Hiring of kiosk operators by the SCSP. The SCSP can hire e-entrepreneurs, e-pensioners, self-help workers etc., to man the kiosks and provide services to RSBY beneficiaries

District / block


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Management Information System for proposed RSBY implementation

Management Information System (MIS) is one of the most important tools to track the progress and effectiveness of a program. A good MIS system

provides a robust decision support system to the management / executive(s).

In a scheme like RSBY, the importance of MIS increases manifold due to multiple stakeholders and the complexity involved. The complexity increases with

the spread of the scheme across 28 states and the large number of beneficiaries involved.

MIS for RSBY plays a very crucial role in providing an understanding of the way the project is functioning on a daily/ monthly/ quarterly/ half

yearly/yearly basis. The data reported in such MIS will be helpful in understanding the trends in healthcare amongst the un-organized sector, which can

further help the government in enhancing the health seeking behaviour within this sector through various policy and process mechanisms.

RSBY being an evolving scheme, with dynamic ground level complexities, a strong MIS will play a very crucial role in its success. The focus on designing

the MIS has been the beneficiary, wherein each stakeholder in RSBY will have access to relative information about how the beneficiary in benefitting from

the program, so as to make the RSBY service delivery much more efficient for the beneficiary.

The reports generated by MIS will be primarily of two types:

1. To measure the progress of scheme, MIS will primarily be used as a Decision Support System by the Executive Management Committee at Central

Government level, thereby facilitating policy decisions and understanding benefits being accrued by the targeted beneficiaries.

2. To measure the key performance indicators of each stakeholder and the regional progress, MIS will be available at State / District level. This will

allow close monitoring of the scheme within each State / District, as well as monitoring of hospital and insurance company performance to help

the stakeholders take remedial measures to make the scheme efficient.

The MIS reports should be designed on the basis of their periodicity which will be available through the web based platform and can be classified under

following categories:

1. Fixed periodic (Daily, weekly, Monthly, Quarterly & annual) report

2. Fixed periodic (Daily, weekly, Monthly, Quarterly & annual) exception report

3. Exception report on the basis of pre-defined triggers

4. Detailed report generated by business intelligence team

5. Reports to be made available in the public domain (it will be sub-set of the above four reports)


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While the periodicity has been defined for must-have analysis, the data that are generated through the system should be available for ad-hoc reporting in

real-time/near-real-time. The following reports have been identified and listed for each of the 8 processes within RSBY. The MIS list is not exhaustive and

will undergo changes over a period of time based on the information requirements or structural changes or policy changes within the scheme.

Process I – Data preparation and pre-enrolment

MIS Reports

Sr. No

Name of MIS Report Filters Fields Role based access to19:

Remarks

1

Pre-enrolment data fields (This is not necessarily a report, but a mode to allow authorized users to search for one or more fields in the database) to drill down to specific records

Geography, Category (11), Caste Category, Period (From, to)

S.No., Name of Beneficiary*, Father’s/Husband’s name, Date of birth / Age*, Gender*, Address*, VTC* (Village/Town/City), District*, State*, Pin-code, Caste Category (SC/ST/OBC/General), BPL category (out of 11)*, Date of pre-enrolment*, Number of dependents to be covered*, Mobile number, Aadhaar number, NPR number, NREGS Job Card number, BPL Card Number, Ration Card number, Category Identifier number (for any of the 11 categories), Existing RSBY Card Number, URN number, flag to indicate whether any family member has an RSBY card* (Y/N)

MoLE, Corresponding state department, SNA

1. State department data available to department for only those beneficiaries for which the data has been collected by that department

2. Mandatory fields have been marked as *

3. The refreshed data should be available daily for search

4. Data should be made available on the proposed web application for authorized users

2. Category wise pre-enrolment data report

Village, Block, District, State, Period((From/To), Caste Category, Only

Name of Category*, Number of pre-enrolment data records collected, Number and % of pre-

SNA 1. Mandatory fields have been marked as *

19

Not all information is available to everyone. Each stakeholder gets to see the information that is required for him / her to take necessary action


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MIS Reports

Sr. No

Name of MIS Report Filters Fields Role based access to19:

Remarks

The reports using an ad-hoc query builder would take into account multiple filters and one or more parameters.

records with valid NPR number /Aadhaar number / Mobile number/NREGS ID/BPL card number / Ration card number.

enrolment data records rejected due to duplication, Number and % of pre-enrolment data records rejected due to invalid structure/format

2. The refreshed data should be available daily for search

3. The report should be made available on the proposed web application.

Process II- Enrolment

MIS Reports

Sr. No Name of MIS report

Filters Field Role based access to20

Remarks

1 Area wise % enrolment

Village, Block, District, State, period (from-to)

S.No., area (Village/Town/City, District*), Number of pre-enrollments, number of URN generated, number of actual enrolments, % of enrolment from URN generated

MoLE, SNA, DKM, SCSP, IC

1. The reports should be made available through the proposed web application

2. List of areas with % coverage between


S.No., area (Village/Town/City, District*), Number of pre-enrollments, number of URN generated, number of

MoLE, SNA, DKM,

1. This report would be used to identify slab-wisecompletion

20



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MIS Reports



Remarks

x1 and x2

X1, x2 can have values of 0, 10, 20, 30…90, 100.

actual enrolments, % of enrolment from URN generated SCSP, IC of enrolment

2.

3 Number of villages with more than 5% variation between number of signed and FKO data


S.No., area (Village/Town/City, District*), Number of FKO card Data, number of Signed data, , variation


This is an exception report, should be monitored

4 Report of villages where enrolment could not start

Block, District, State

S.No., area (Village/Town/City, District*), Scheduled date of enrolment


This is an exception report, should be monitored closely

5 Activation of cards

Village, Block, District, State, PHF, period (from-to)

S.No., area (Village/Town/City, District*), Number of enrollments, number of cards activated, % of activated cards


The reports should be made available through the proposed web application to understand the extent of wellness check completed

6 Addition of family members

Village, Block, District, State, Kiosk Operator, period (from-to)

S.No., area (Village/Town/City, District*), Number of enrollments, number and % of cards for which additional family members have been added


The reports should be made available through the proposed web application to understand the impact of kiosk in addition of family members to RSBY card


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MIS Reports



Remarks

7 Area wise spilt of cards and issue of new cards

VTC, District, State, IC, Kiosk Operator, period (from-to)

S.No., area (Village/Town/City, District*), Number of enrollments, number and % of families for which additional cards have been issued, number and % of families for which additional cards have been issued due to family split, number and % of families for which additional cards have been issued due to lost card replacement,


The reports should be made available through the proposed web application to understand the impact of kiosk in issuance of new card due to family split or lost card replacement

Process III – Smart card and key management system

MIS Reports

Sr. No Name of MIS report Filters Field Role based access to21

Remarks

1 Number of cards issued

State, District, Block, Village, master, beneficiary, Hospital, Kiosk, PHF, DIO, DKM, FKO, period (from-to)

S.N,, Number of cards issued, % of total cards issued

MoLE, SNA, DKMA, IC,SCSP

To be available in public domain

21

Not all information is available to everyone. Each stakeholder gets to see the information that is required for him / her to take necessary action. In some cases, depending on the filter, some new fields would appearin the report. For example, if State name is selected as filter, district name should appear as a field. If district is selected as filter, block/villages would appear in the fields. The user of the MIS should be allowed to select the filter(s) and the fileds that should appear in the report


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MIS Reports

Sr. No Name of MIS report Filters Field Role based access to21

Remarks

2. Number of cards hot-listed

State, District, Block, Village, master, beneficiary, Hospital, Kiosk, PHF, DIO, DKM, FKO , period (from-to)

S.N., Number of cards hot-listed, % of total cards hot-listed

MoLE, SNA, DKMA

To be monitored by MoLE, SNA, DKMA

3 Number of duplicate cards issued

State, District, Block, Village, master, beneficiary, Hospital, Kiosk, PHF, DIO, DKM, FKO, Period (from-to)

S.N., Number of duplicate cards issued, % of total duplicate cards issued

MoLE, SNA, DKMA

To be monitored by MoLE, SNA, DKMA

Process IV – Wellness check and payment of premium

MIS Reports

Sr. No Content of MIS Report

Filters Fields Role based access by22

Remarks

1 Wellness check completion

State, District, Block, Village period (from-to), PHF, flag on wellness data updated in the system, flag on wellness-check completed-within-first-two-months, flag on wellness-check-completed-between-second-and-third month

S.N., number of families (cards) with wellness check completed, number of families (cards) with wellness check pending, % of wellness check completion

MoLE, SNA, DKM, PHF, IC/ SCSCP

1. The MIS report aims to provide numbers and details on wellness check

2. The numbers may be computed on various parameters/filters which are available as a field

22



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MIS Reports

Sr. No Content of MIS Report

Filters Fields Role based access by22

Remarks

2

Time taken to pay the premium (by SNA or by MoLE)

State, District, 100% premium payment cases, 50% premium payment cases

S.N, Average time taken to make the payment to IC

MoLE, SNA, DKM

1. This MIS report will provide details on the timely payment to IC’s after wellness check

Process V – Hospital Management

MIS Reports

Sr. No Name of MIS report Filters Field Role based access by23

Remarks

1

Number of hospitals empaneled

State, district, block, IC, S.N., number of hospitals empaneled, type of hospital (public/private)

MoLE, SNA, DKMA, IC/TPA

The MIS report will provide number of hospitals empaneled in an area

23



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MIS Reports

Sr. No Name of MIS report Filters Field Role based access by23

Remarks

2.

% of hospitals reporting claims (empaneled and non-empaneled)

State, district, block, type of hospital (public/private), IC/TPA, period (from, to)

S.N., number of hospitals empaneled, number of hospitals reporting claim, % of hospital reporting claim,

MoLE, SNA, DKMA, IC/ TPA

The MIS report will provide the number and % of hospitals who have raised claims during a period

3

Number of blocks without empaneled hospital

State, district S.N. number of blocks without empaneled hospital, total number of block in the district


This is an exception report and need to be monitored closely

4

Report to track status of training provided to hospitals during a period

State, district, block, IC, hospital type (public/private), period (from, to)

S.N., number of hospitals empaneled, number of hospitals with training completed flag


1. The MIS report aims to provide the details on number of hospitals that have been provided training during a period

5 List of hospitals with high number of manual overrides

State, district, block, IC, hospital type (public/private), range of % manual override

S.N., number of hospitals empaneled, number of manual over rides, total number of claims, % of manual override with respect to total number of claims

MoLE, SNA, DKMA

The MIS report will provide the list of hospitals using manual override option more frequently

6

Number of hospitals with hardware and software issues

State, district, block, IC, hospital type (public/private), date

S. N., number of hospitals empaneled, number of hospitals with reported non-functional SW/HWs, % of hospitals with reported non-functional SW/HWs

MoLE, SNA, DKMA

1. The MIS report will provide the number and % of hospitals that are non-functional due to hardware and software issues


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Process VI – Claims Management

MIS Reports


Filters24 Fields Role based access to

Remarks

1 % of Claim settled (number)

State, district, block, hospital, IC, period (from-to)

S.N., number of claims raised, number of claims settled, % of claimed settled in numbers, amount of claims raised, amount of claims settled, % of claimed settled in amount

MoLE, SNA, DKM, IC/TPA, Hospital

This report will provide status of claim settlement in a geography during a period

2 List of pending claims

State, district, block, hospital, IC, package code

S.N., claim id, amount of claim raised, claim date, pending for (days),


This report will provide list of all pending claims, which can be prepared for a geography, for an IC, for a hospital or for a package code

4 % of claims partly paid

State, district, block, hospital, IC, period (from-to), package code

S.N. no of claims raised, number of claims partly paid, % of claims partly paid


This report will provide % of claims which are partly paid by IC

5 Time taken to settle the claim

State, district, block, hospital, IC, time taken to settle the claim ( e.g. % of claims settled in 7 days, 15 days, 30 days), package code

S.N., total number of claims settled, number of claims settled during the period, % of claims settled during that period


This report will provide information about time taken to settle a claim, by an IC for a hospital for a package

24

One or more filters may be applied to data table with fields to generate desired MIS report


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Process VII – Complaint and grievance redressal management system

MIS Reports

Sr. No

Content of MIS Report Filters Fields Role based access by25

Remarks

1 Status report of complaints

Medium of logging complaint (National call center, online through CGRMS, post etc), state, district, block, Complaint type,

S.N., number of complaints received, number of complaints resolved, average time taken for resolution, % of complaints turned in to grievance

MoLE / SNA/ NGRC / SGRC / DGRC / DKM

This report will provide an overview of status of complaints received through different channels

2 Status of grievances state, district, Grievance type

S.N., number of grievance received, number of grievances closed, % of grievances closed, % of decisions against which appeal was made

MoLE, SNA, NGRC, SGRC, DGRC

This report will provide summary of status of grievances on a particular day

Process VIII – Kiosk management

MIS Reports

Sr. No

Content of MIS Report Filters Fields Role based access by26

Remarks

1 Uptime of each kiosk at district and block level

State, district, block, Kiosk type (district / block),

S.N., number of kiosks, average uptime during the period, % of days when uptime was more than X%

MoLE / SNA / DKM/ IC/TPA

The MIS report will provide status of the kiosk in terms of uptime

2 Transactions carried out at kiosks

State, district, block, Transaction type (modify, update, card replacement, complaint registration, grievance registration, status update to beneficiary),

S.N., number of transactions, average Time per Transaction, % of offline transactions with stand-alone software, % of offline transactions synchronized with state / central server

MoLE / SNA / DKM/ IC/TPA

The MIS report will provide snapshot of transactions being carried out at kiosks

25

Not all information is available to everyone. Each stakeholder gets to see the information that is required for him / her to take necessary action 26



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Third party audit of RSBY processes

RSBY involves varied number of transactions being conducted at different places by different stakeholders. The existing processes and software leaves

scope for mal-practice at many places. It is imperative to track and monitor these transactions and activities through IT interventions. While not all the

activities can be tracked directly through IT interventions, some of these require field level visits to check conformity to the processes. The concept of

audit of RSBY processes and activities is being brought in for the first time. Various sub-groups have had consultations and

It is hence proposed to introduce various types of audits on the activities taking place in various processes of RSBY. In some cases audit will be

concurrent while for some it will be periodical. This section lists downs the activities which need to be audited. It also mentions the frequency and sample

size for which this audit is need to be conducted. Third party audit agencies will be selected for conducting such audits and these firms will be empaneled

centrally. An indicative list of audit types has been provided below:

Concurrent audit: This will happen in case of activities, where the number of transactions are of high value and regular, such as enrolment and card

issuance by SCSP, kiosk etc.. In these cases the frequency will be high but % of cases selected as sample will be low.

System audit: All application/software developed will undergo functionality testing before going live and IT security audit should be conducted during first

year of operations. A regular system audit may be done as and when changes to the system take place or a random system audit may be conducted.

Medical audit: a team of qualified doctors will conduct the audit of randomly selected cases to verify whether the treatment given provided was actually

required or whether the requisite treatment was actually given or not.

Field audit: This will comprise of field checks, such as for wellness checks, kiosk operations. This type of audit can be initiated at any time based on

exceptions from MIS/ field reports/ call center complaints.

For all the audits following points should be taken in to account:

1. Sample will be selected purely on random basis. System will have the provision to generate random samples for audit

2. In some cases system will generate random samples from select datasets on the basis of pre-defined triggers

3. Sample will be generated maximum 12 hours before the actual audit is scheduled.

4. Audit has to be conducted within 12 hours of sample generation

5. Audit report has to be uploaded to the system within 24 hours of audit

Who will conduct the audit: Audit will be conducted by firms that have been centrally empaneled by MoLE. These firms shall have prior experience of

conducting audits of similar nature. These firms can be chartered accountancy firms (based on the kind of audit) and other firms that have extensive field

level experience and specific expertise to suit the audit requirements of RSBY. These firms shall have multi-disciplinary expertise in-house or empaneled


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to conduct the requisite audit for RSBY procedures. The audit firms shall sign an undertaking that none of the partners / members of the team of auditors

of the firm face any disciplinary action on account of frauds or collusion or any act which can be construed as moral turpitude, during the empanelment

process and prior to executing an audit as desired by MoLE.

Selection of audit firms: The audit firms shall be selected on a zonal basis. The States and Union Territories shall be divided into five zones – North East

West South and Central. A minimum of two audit firms shall be selected and they would be allocated states and select districts for audit based on an RFQ

by the State Nodal Agency (SNA). The audit firm shall be selected on a zone wise basis. Once they have been selected on a zonal basis they can be

allocated work in any state in the zone for a period not exceeding one year in the state and a maximum of three years in the zone.

Disqualification of audit firms: In the process of bidding in case it is found that an audit firm tries in any way to approach or influence members who shall

select the firms there shall be automatic disqualification. In case the audit firm or any partner has any professional or any other interest in the activity of

any stakeholder, it shall have to be disclosed and in case not done and found later would attract disqualification. In case the conflict of interest is

substantial lie the auditor is also auditing a stakeholder or is on the board of an IC in the state concerned, there shall be automatic disqualification at the

selection stage.

Suggested audits in each process of RSBY: The list below provides for suggestive audits that can be conducted for each sub-process of RSBY. MoLE /

SNA can change/ add additional audit parameters based on the requirements and the status of the project/ issued observed in operations. It is envisaged

that the proposed web based application shall provide reports which MoLE / SNA can use for initiating audits apart from field reports, call center

complaints etc.

Process No- I: Data preparation and pre-enrolment

Audit required

Sr. No

Activity/systems to be audited Entity involved Audit agency Sample size Sample type Periodicity Triggers

1 De-duplication process

SNA 3rd party Audit Team

5% of suspicious cases

Randomly generated by system from pre-enrolment data submitted by

Once at the time of enrolment data preparation, before submitting the data to mole

High number of potential duplicate records found at MoLE


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Audit required

Sr. No


departments

2 Accuracy and completion of data shared by departments

Department Field Audit team

0.1% of complete data

Randomly generated by system from pre-enrolment data submitted by departments

Once at the time of enrolment data preparation, before submitting the data to mole

Sudden rise or fall in number of beneficiary from a particular category

3 Reporting of “Active” and “Inactive” family

SCSP Field audit team

5% of data Randomly generated by system from enrolment data submitted by IC

At least once during enrolment period

Process No – II: Enrolment

Audit required

Sr. No Activity/systems to be audited Entity involved

Audit agency Sample size Sample type

Periodicity Triggers

1 Setting up of enrolment stations

( time, quality of equipment, IEC activity,

SCSP 3rd party agency

5% Randomly selected system

At least once a week, during enrolment

Complaints against a particular SCSP


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Audit required

Sr. No Activity/systems to be audited Entity involved

Audit agency Sample size Sample type


quality of cards, re-verification of cards, presence of FKO, extent of family data updated)

generated records from the master set

window Continuous low coverage by an SCSP

2

Quality of fingerprint captured

Phase I: SCSP to provide biometric data of randomly selected URN to audit agency

Phase II : Audit agency to randomly fetch data from central database

SCSP 3rd Party agency

5% Randomly selected system generated records from the master set

Continuous basis,

High number of manual overrides from a particular district

Process No. – III: Smart card and Key management system

Audit required

Sr. No Activity/systems to be audited

Entity involved

Audit agency Sample size

Sample type Periodicity Triggers

1 FKO card personalization

DKM/ADKM Field Audit Team

5% System generated random sample

At least twice, during FKO card personalization period

Same FKO card is being used in more than one village

2 Beneficiary card issuance

FKO Field Audit team

0.1% System generated random sample

At least twice during enrolment period

Too high or too low coverage

3 KMS system audit CKGA/DIO/D System Audit NA System generated Before start of every Complaints of non-functioning of master


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KM/FKO team random sample enrolment cards

Process No. IV – Wellness check and payment of premium

Audit requirements

Sr. No

Activity/systems to be audited

Entity involved Audit agency

Sample size


1

Wellness check audit

MoLE / SNA 3rd party audit agency

1% Randomly selected system generated records from the master set

Once a year post enrolment process

Only for data sets for which wellness check has happened

2

Premium payment system audit


NA System generated records from master set

Once a year A complete system audit for functionality and information security

Process No. V – Hospital management

Audit required


Entity involved

Audit agency Sample size Sample Type Periodicity Triggers

1 Claims raised by hospital Insurance company

Insurance companies

1% of total cases

Randomly selected system generated records from the master

At least once a month

Too many claims of similar types from


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Audit required


Entity involved

Audit agency Sample size Sample Type Periodicity Triggers

and

3rd Party Audit agency

set same hospital

Other triggers are listed in Annexure 5.2 of claims management

2 Empaneled hospitals for facilities claimed to be available

Insurance company

Insurance company and

3rd Party Audit agency

10% of total empaneled hospitals

At the time of receipt of application from the district committee.

Randomly selected system generated records from the master set, as well field reports from beneficiaries, call center complaints, reports from pensioners

Once in a year spread across various states / district

Field reports and complaints received through call center and other mediums that have been recorded in the web system.

3 Audit to check whether the beneficiary has been provided with cash of Rs. 100 at the time of discharge, towards transportation allowance.

Hospital 3rd Party Audit agency and insurance company

2% of beneficiaries in each state

Randomly generated system data, feedback from beneficiary through call center/ CGRMS, reports from pensioners

Once a month in randomly selected districts

Complaints and field reports from beneficiaries and pensioners through call center/ letters and other mediums


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Process No. VI – Claims management

Audit required


Entity involved

Audit agency

Sample size


1 Claims raised by hospital

Hospital 3rd party agency

1% System generated random sample from hospital claim data

Continuous process with audit at hospital or at beneficiary location happening at random

Unusually high number of claims raised by a hospital during a specific time duration

2 Claims rejected by IC IC or hospital

3rd party agency

10% System generated random sample from hospital claim data

Continuous process with audit at hospital

Very high claim reject percentage by a specific IC, or for a hospital

Process No. VII – Complaint and grievance redressal management system

Audit requirements

Sr. No


1 CGRMS system audit MoLE / SNA 3rd party audit agency

NA Complete system

Once a year before commencement of enrolment

New features / modules added

2 Complaint audit MoLE / SNA 3rd party audit agency


At least twice a year

Type of complaint, pending complaints


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Audit requirements

Sr. No


3 Grievance audit MoLE 3rd party audit agency


At least twice a year

Type of grievance, pending grievances, number of appeals

Process No. VIII – Kiosk Management

Audit requirements

Sr. No

Activity/systems to be audited

Entity involved

Audit agency Sample size


1 Kiosk audit


10% Twice a year Audit teams should conduct surprise audits to check the state of kiosks on parameters such as functioning hardware, designated kiosk operator presence, service delivery satisfaction by beneficiaries through a kiosk.

2 Fraudulent access to kiosk software


Based on exception reports

This can be conducted in case such events are reported in the MIS exception reports.

There may be instances when unauthorized access takes place in the kiosk software. This may be due to wrong entry of password by the kiosk operator, biometrics not matching due to faulty biometric reader; user apart from kiosk operator tries to access the software etc. Each such reported instance will have to be audited.


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Annexures

Annexure 1.1 – Guidelines on prioritization of beneficiary categories for de-duplication

1. Beneficiaries shall be prioritized based on the amount of premium to be paid by him. The categories for which the beneficiaries have to

pay the lowest premium will get highest priority. In case the premium to be paid by beneficiary is same for two categories, the

beneficiary will be considered under the category, where number of beneficiaries is higher. However if the premium for a particular

category is being paid by the respective agency then that category will have higher priority, even if the number of beneficiaries is lower

than any other category. At the de-duplication stage while selecting a record, the beneficiary with category in higher priority should be

given preference. E.g. a beneficiary from BOCW will be given highest preference as the premium paid by beneficiary is only Rs. 30.

2. The priority will be in this order

a. BOCW (100% premium to be paid by BOCW + 30 rupees fixed fee to be paid by beneficiary)

b. All other categories except those mentioned in (a), (c) & (d) the (beneficiary to pay 30 rupees fixed fee

c. Colie/porters (25% premium to be paid by beneficiary + 75% premium to be paid by Ministry of Railways)

d. Auto Rickshaw/Taxi Drivers (50% premium and Rs. 30 fixed fee to be paid by beneficiaries + 50% premium to be paid by central and

state departments)

Annexure 1.1 (a): Categories of beneficiaries

S.

No

Category National

Estimated

Numbers

Eligibility Criteria for getting RSBY benefits Nodal Department /

Agency

1 Below Poverty

Line (BPL)

Rural: 2209.24

Lakh lives or

441.84 Lakh

households

Urban: 807.96

Lakh lives or

161.59 Lakh

The definition of BPL would be the one prescribed by the Planning

Commission for the purposes of determining the eligible BPL population in

each State/district. It would be the responsibility of the respective State

Government to verify the eligibility of specific BPL workers

Rural Development

Department of the State

Government for Rural

BPL

Urban Local Bodies of

the State Government


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S.

No

Category National

Estimated

Numbers


Agency

households

(as per NSSO 61st

Round 2004-05)

for Urban BPL

2. Building & Other

Construction

Workers

4.46 crore

(as per NSSO

2009-10)

Registered with the Building & Other Constriction Workers Welfare Boards

(Premium is paid by the Welfare Boards from the Cess collected)

State Labour

Department (BOCWW

Board)

3. Street Vendors 42.19 Lakhs

(as per census

2001)

Registered urban street vendors (as per the National Policy on Urban

Street Vendors 2009) with Town Vending Committee in the

Municipalities/Urban Local Bodies

State Government /

Urban Local Bodies

4. MGNREGA

Workers

350.00 Lakhs Workers having worked for at least 15 days in the preceding financial

year.

Rural Development

Department of the State

Government

5. Beedi Workers 49.80 Lakhs

(I-cards have been

issued to them)

Beedi Workers identified and registered by the State Governments State Labour

Department (Labour

Welfare Commissioners)

6. Domestic Workers 47.50 Lakhs

((NSSO 61st

Round 2004-5)

any two of the following criteria:

Certificate from RWA to the effect that a person is working as a domestic worker in the area

Employer Certificate

Certificate from a registered trade union that the concerned person

State Labour

Department/ Urban

Local Bodies


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S.

No

Category National

Estimated

Numbers


Agency

is working as a domestic worker Police verification certificate which certifies that the person is

working as a domestic worker

7. Railway Porters Approx. 50

thousand. SO?

Licensed Porters, Licensed Vendors and Licensed Hawkers Railways

8. Sanitation

Workers

10.08 Lakhs

(as per census

2001)

Sanitation Worker’ means a person engaged in, or employed for, any

sanitation work, other than manual scavenging. This includes Sewage

Labourers and Sweepers. State Government will prepare Data

State Government /

Urban Local Bodies

9. Rickshaw

Drivers/Pullers

13.68 Lakhs

(as per census

2001)

Cycle Rickshaw driver driving cycle rickshaw on hire or as paid employee

to transport passengers. Rickshaw pullers pulls hand rickshaw on hire or

as a paid employee to transport one or two passengers/goods from one

place to another in urban areas or on hills assisted by one or more pullers.

State Government will prepare data

State Government /

Urban Local Bodies

10. Mine Workers 17.79 Lakhs

(NSSO 61st Round

2004-5)

Employment in hazardous mining and quarrying industry. List of

Hazardous Mines given in Cabinet Note

State Government (State

Department of Mines)

11. Rag Pickers 11.63 Lakhs

(as per census

2001)

More than 18 years of age, a self-declaration that he/she is rag picker and

any one of the following document:

Letter from Mohalla Committee/RWA/Area Sabha/Ward Committee/ Commercial Complex/ Hotel Management stating that picker is collecting waste from their premises.

Membership of an organisation for the benefit of rag pickers (like their trade unions)

Letter from scrap dealer

State Government /

Urban Local Bodies


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S.

No

Category National

Estimated

Numbers


Agency

Any Identity card issued by the ULB or State Government or Government of India certifying that he is waste picker

12. Auto/Taxi Drivers 35.39 Lakhs Auto/Taxi Drivers registered with State Transport Authorities

State Government /

Transport Department

13 Weavers and

Textile workers

15 lakhs Use of RSBY platform for IPD and OP benefits. Ministry of textiles

Annexure 1.2 – Data De-Duplication Process

The de-duplication should be a two stage process,

Stage 1: In the first stage, the system would prompt for potential duplicate records, but no final decisions of accept/reject is taken.

Stage 2: In the second stage, the SNA official would accept/reject the record based on pre-defined guidelines.

The rules for deduplication checks using the web-application should be defined in the following manner.

a) Check Aadhaar number availability in both records. If there is an exact match, flag as duplicate. If no, move to next step.

b) Check NPR number availability in both records. If there is an exact match, flag as duplicate. If no, move to next step.

c) Check Mobile number availability in both records. If there is an exact match, flag as duplicate. If no, move to next step.

d) Follow similar steps for NREGS ID, BPL card number and Ration card number.

(v) Check on demographic data based on exact/partial/fuzzy match. The details would be defined in the system FRS. (utmost care to be taken while deciding whether the record is duplicate)


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Annexure 1.3 – Revised RSBY Data Format

A. Location Particulars 1 State

3 Sub-district

2 District

4 Village/Town

5 GP/Ward

B. Family Details C. Family Identifiers

1 Family Name (Surname)

S. No. Scheme Card Number

2 Address 1 BPL (Rural) Card Number

2 BPL (Urban) Card Number

3 Ration Card Card Number

3 Pin-code 4 RSBY Old URN

4 Local Language 5 RSBY Chip Number

5 Minority 6 NREGS Job card number

6 Caste category 7

8

7 Category to be covered


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D. Family Members

S. No.

Member Name in (a) English (b) Hindi and (c) Local Language

(a) DoB type (Verified, Declared, approximate) (b) DoB (c) Age

(a)Sex (b)Marital Status (c)Relationship with Head

Name of (a) Father, (b) Mother & (c) Spouse in full

(a) Phone, (b) Mobile & (c) Email

Category of Worker (11) (upto 3 category)

Corresponding Category Card No.

(a) NPR (b) Aadhar (c))Old URN

1 a

b

c

2

a

b

c

3

a

b

c

4

a

b

c

5

a

b

c

6

a

b

c


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Annexure 2.1: Checklist for enrolment station

S. No. Description Requirement

1 Number of enrolment kit As per population of village, to be calculated @ one kit for 100 family

2 Electricity backup 1 for every enrolment station

3 Operator 1 per kit

4 Supervisor 1 per 5 operator

5 Technician 1 per 10 kit

6 IEC coordinator 1 per 5 enrolment kit

7 Field manager 1 for every 5 supervisor

8 IEC material Brochure: 1 per family Flex Board: 2 per enrolment station One showing enrolment process, another showing benefits of RSBY scheme

Components of enrolment kit - An enrolment kit includes the following:

1. A smart card printer, 2. Laptop, 3. Two smart card readers, 4. One fingerprint scanner, 5. Web camera, 6. Certified enrolment software and other related software.

Specifications for hardware and software requirement at enrolment station

Hardware components Remarks District / block kiosk

Laptop

► This should be capable of supporting all other devices required.

► It should be loaded with standard software as per specifications provided by the MoLE

Configuration:

Desktop with dual core processor with 2 GHz, 80 GB hard drive, DVD r/w drive, 2 GB RAM, graphics

card, minimum of 4 USB ports etc.

District and block kiosk


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Fingerprint Scanner /

Reader Module

(1 in number)

► Thin optical sensor

► 500 ppi optical fingerprint scanner (22 x 24mm)

► High quality computer based fingerprint capture (enrolment)

► Preferably have a proven capability to capture good quality fingerprints in the Indian rural

environment

► Capable of converting fingerprint image to RBI approved ISO 19794-2 template.

► Preferably Bio API version 1.1 compliant


Camera

(1 in number)

► Sensor: High quality VGA

► Still Image Capture: up to 1.3 megapixels (software enhanced)

► Native resolution is 640 x 480

► Automatic adjustment for low light conditions


Smartcard Readers (2 in

number)

► PC/SC and ISO 7816 compliant

► Read and write all microprocessor cards with T=0 and T=1 protocols

► USB 2.0 full speed interface to PC with simple command structure

► PC/SC compatible Drivers


Smart card printer

► Supports Color dye sublimation and monochrome thermal transfer

► Edge to edge printing standard

► Integrated ribbon saver for monochrome printing

► Minimum printing resolution of 300 dpi

► Prints at least 150 cards/ hour in full color and up to 1000 cards an hour in monochrome

► Minimum Printing resolution of 300 dpi

► Compatible with Windows / Linux

► Automatic or manual feeder for card loading

► Compatible to Microprocessor chip personalization

► USB connectivity

► Printer with hardware/software protection to disallow unauthorized usage of printer

► Inbuilt encoding unit (ISO7816 and PCSC compliant) to personalize microcontroller chip

based contact cards in a single pass

► Smart card printing ribbon as required

District kiosk

Fingerprint scanner ► The fingerprint capture device at enrolment as well as verification will be single finger type

► Compliance with “fingerprint_image_data_standard_ver.1.0” mentioned on



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www.egovstandards.gov.in. All specifications confirming to ”Setting level 31” will be

applicable for RSBY related enrolment and verification

► The images should be stored in .png format

Power backup ► UPS of capacity 860VA or higher

► Minimum 8 hours of power backup for specified hardware set


Telephone Line (1 Nos.) ► This is required to provide support as a helpline District and block kiosk

Internet Connection ► This is required to upload/send data/ access the web based software for RSBY District and block kiosk

Master Kiosk card ► The card issuance system should be able to personalize a 64 KB NIC certified SCOSTA smart

card for the RSBY scheme as per the card layout.


http://www.egovstandards.gov.in/


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Annexure 2.2: Information to be provided in Brochure

1. Details of benefits available under RSBY Scheme

► Facilities available

► Exclusion list

2. How to avail the benefits

3. Do’s and Don’ts

4. FAQs

5. Details of empanelled Hospitals

6. Toll Free Number

Annexure 2.3: Format for reporting Awareness and Sensitization workshop conducted by IC at district/block

S No Description Response Remarks

1 Date of Workshop

2 Venue

3 Person present in the workshop (attach attendance sheet)

4 Route Plan discussed (Y/N)

5 Changes suggested in route plan

6 Route plan finalised (Y/N)


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Annexure 2.4: Suggestive guideline for Route Planning

1. Route plan should be an iterative process

2. At first stage SCSP along with DKM should create a broad route plan for district, it should be a macro level plan and should be in following format

S.No. Block Population Number of village Estimated number of days required Tentative Start date Number of Kits required

3. This plan should be discussed and finalised in workshop conducted at District along with block/taluka level functionaries

4. In second stage representatives of SCSP and Block functionaries should prepare a micro plan in following format

Sr No

Name of village

Population Number of days required

Tentative Start date

Number of kits to be deployed

Proposed enrolment centre (School/Panchayat Bhavan etc.)

Name of FKO

Name of Supervisor (SCSP)

5. This plan should be discussed and finalised in workshop conducted with FKOs at Block level in following format

Sr No

Name of village

Population Number of days required

Date Number of kits to be deployed

Proposed enrolment centre (School/Panchayat Bhavan etc)

Name of FKO

Name of Supervisor (SCSP)

6. While finalising the route plan following points to be considered:

► It should cover each and every village of the district/block

► Villager should not be made to travel more than a kilometre for enrolment

► It should preferably start from the area where number of hospitals are more


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Annexure 2.5: Daily report and undertaking by FKO

Rashtriya Swasthya Bima Yojna Daily Report by Field Key Officer

Name-

Date Gram Panchayat

Block Village

Sr. No Activity Response Remarks

1 Arrival time of team

2 Enrolment start time

3 Enrolment completion time

4 Number of kits required as per route plan

5 Number of kits available

6 Number of kits in working condition

7 Number of kits actually used

8 Number of beneficiary family as per route plan

9 Number of families enrolled today

8 Whether IEC material were used at enrolment station If yes give the details

9 Whether brochures were given to each beneficiary

10 Whether plastic cover were given along with card

11 Whether cards were given on the spot

12 How much money was collected from each family

13 Have you received any incentive for this work


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UNDERTAKING BY THE FIELD KEY OFFICER

I, _________________________________________ Designated as Field Key Officer for Rashtriya Swasthya Bima Yojna as per following:

Date and Duration:

Village (s) Name:

Block:

District:

State:

Hereby, declare that I was present at the RSBY enrolment station and have performed all the tasks assigned to me to the best of my ability.

Total number of RSBY families, which were enrolled and, verified by me are _________

SIGNATURE Name

Designation

Date:


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Annexure 3.1: Data fields on the beneficiary RSBY card

Balance on Card

Field Data

Issue date Card issue date

Validity Card validity date

Balance Available Balance

BalModDat Last Balance Modified date

AddOnBal Available Balance for add on packages.

AddOnBalModDate Last Add on Balance Modified date

Policy Extension file

Field Data

Policy No Policy Number

Policy validity Validity of policy

ExtBy Extension of Policy by card-ID (Authority ID)

ExtAt Extension of Policy at Kiosk (Kiosk Code)

ExtUpDate Extension Update Date

ExtBalance Balance

Mortality Information File

Field Data

Member-ID Member ID

Mortality Mortality (Y/N)


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Annexure 3.2: Beneficiary card specifications Card Specifications

► Microprocessor based Integrated Circuit(s) card with Contacts, with minimum 64 Kbytes available EEPROM for application data or enhanced available EEPROM as per guidelines issued by MoLE.

► Compliant with ISO/IEC 7816-1, 2, 3 ► Compliant to SCOSTA 1.2b Dt. 15 March 2002 with latest addendum and errata ► Supply Voltage: 3V nominal. ► Communication Protocol T=0 or T=1. ► Data Retention: minimum 10 years. ► Write cycles: minimum 300,000 numbers. ► Operating Temperature Range: –25 to +70 degree Celsius. ► Plastic Construction PVC or Composite with ABS with PVC overlay ► Quality Assurance: The compliance certificates will be provided for the quality test under taken with each lot of supply for the processes involved

such as gold plating, chip bonding etc. ► The chip module will be sourced from OEM or their authorized distributors / partners ► Surface: glossy

Card layout

The detailed visual & machine readable card layout including the background image to be used is available on the website www.rsby.gov.in. It is

mandatory to follow these guidelines for physical personalization of the RSBY beneficiary card.

For the chip personalization, detailed specification has been provided in the RSBY KMS document available on the website www.rsby.gov.in. Along with

these NIC has issued specific component for personalization. It is mandatory to follow these specifications and use the prescribed component provided by

NIC.

Chip operating system

► SCOSTA-CL (latest copy of SCOSTA from http://scosta.gov.in)

► Valid SCOSTA-CL compliance certificate from NIC

► Chips will be security certified to common criteria EAL+4 or more

http://www.rsby.in/


http://scosta.gov.in/


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Chip security

► Chip module will be manufactured in EMV certified facility

► The derived key though the Key Management System (KMS) will be embedded into the chip during fabrication

Card Body

► The artwork of the design for the card body with all security features will be done through the National Institute of Design – Ahmedabad.

► The card body will be of glossy surface, PETG (50%) plastic construction sandwiched between PVC layers with overlay to allow colour dye

sublimation (dye diffused thermal transfer) printing.

► Operating ambient temperature range should be -25 degrees Celsius to +70 degree Celsius

Visual security

► Guilloche Pattern

► Micro text

► Card serial number will be printed on the card for traceability


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Annexure – 4.1: Components of wellness check

Components Elements

Establishment of the beneficiary’s medical/family history

At a minimum, collect and document the following:

1. Medical events in the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the beneficiary at increased risk;

2. Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments; and

3. Use of or exposure to medications and supplements, including calcium and vitamins

An assessment can be undertaken by Medical or Para Medical staff posted at the Institution

Obtain the following measurements: (minimum)

1. Height, weight, body mass index (or waist circumference, if appropriate), and blood pressure; and

2. Other routine measurements like Urine Sugar/ Albumin, Hb% ,and PS for MP or any other investigations as deemed appropriate, and available at the intuition based on medical and family history

Treatment 1. Fever or general complaints.

2. Preventive Immunizations 3. Collection / utilization of Family welfare services

Counselling and advise For availing benefits under different schemes

1. Family welfare and immunization activities 2. Counselling for HIV/STD if available


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Annexure 4.1 (a): Health Check Template

1. Demographic Information: to be populated from the card.

2. Capture the mobile number and Aadhar number or NPR number if not captured at the time of enrolment or if they are not same.

The following information can be stored on the beneficiary card and this information can be seen and populated by use of TMS at any hospital and is useful

at the time of emergency when the patient is unconscious.

a. Patient History:

1. Habits: 1. Smoking 2. Alcohol 3. Drug abuse

2. History of pre-existing conditions: 1. Hypertension 2. Diabetes 3. Asthma, chronic bronchitis 4. Bleeding Disorders 5. Epilepsy

3. History of allergies 1. Penicillin 2. Sulpha 3. NSAIDs

3. History of immunisation. These details should again be recorded through a template (i.e. Providing selection in a check-box format) It shall be recorded for below mentioned categories:

a) children of up to 5 or 6 years: 1. Fully immunised as per national schedule 2. Partially immunised - if any of the vaccinations are not taken. 3. If No immunisation

b) Pregnant women: 1. TT 2. TT2

4. History of Previous surgery. (Major procedure only)

1. Head 2. Neck 3. Thorax 4. Abdomen 5. Bone 6. Ob & Gyn


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2. Patient parameters.

1. Height: ( in cms) 2. Weight: ( in kgs) 3. BMI – automatically calculated

4. Blood Pressure: 1. Normal range. 2. Border line 3. Abnormal

5. Blood Group.

1. A Positive 2. A- Negative 3. B- Positive 4. B- Negative 5. AB- Positive 6. AB – Negative

7. O- Positive 8. O- Negative

Along with the above information the following information can be stored on central web application.


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RASHTRIYA SWATHYA BIMA YOJANA

WELLNESS CHECK SCHEDULE:

Name of the PHF: District: State:

Date of wellness check: Time start: Time end:

Name of the beneficiary:

S/o , D/o ,W/o

Smart card URN number

Mobile number / Telephone number of the beneficiary

To be collected from the smart card

Name of the PHF personnel doing wellness check:

Date of wellness check: Time start:

Time end

1. Patient History

Web entry made and

uploaded on ------------------


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1. Habits: 1. Smoking Yes / No

2. Alcohol. Yes / No

3. Drug abuse Yes / No

2. H/O pre-existing conditions: 1. Hypertension Yes / No

2. Diabetes Yes / No

3. Asthma, chronic bronchitis Yes / No

4. Bleeding Disorders Yes / No

5. Epilepsy. Yes / No

3. H/o allergies

1. Penicillin Yes / No

2. Sulpha Yes / No

3. NSAIDs Yes / No

4. H/O of immunisation

children of up to 5 or 6 years:

1. Fully immunised as per national schedule Yes / No

2. Partially immunised,- if any of the vaccinations

are not taken.

Yes / No

3. if No immunisation Yes / No

Pregnant women 1. TT Yes / No

2 TT2 Yes / No


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5. H/O of Previous surgery. (Major

procedure only)

1. Head Yes / No

2. Neck Yes / No

3. Thorax Yes / No

4. Abdomen Yes / No

5. Bone Yes / No

6. Ob & Gyn Yes / No

6. Present complaints H/o of cough for more than 15 days. Yes / No

Sputum with blood. Yes / No

Chest pain with palpitation Yes/ No

Rapid weight loss during last 3 months Yes/ No

Pain and blood in urine Yes/ No

Any episodes of unconsciousness Yes/ No

Blood in stools during/ after defecation. Yes / No

Not able to see properly. Yes/ No

Fever Yes/ No

Is the women Pregnant Yes / No

For women Pain and bleeding during Menses. Yes/ No

Any mass or lump in the breast Yes/ No


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Any mass protruding out and down from below Yes / No

If the answer is Yes to any of the questions at 6, refer for treatment.

7. Patient parameters 1. Height ( in cms)

2. Weight: ( in kgs)

3. BMI – automatically calculated.

4. Blood Pressure

5. Blood Group

6. Haemoglobin

7. Urine Sugar

8. Urine Albumin

8. Treatment Provided Fever or general complaints. Yes/ No

Preventive Immunizations: Yes/ No

Collection / utilization of Family welfare services

Yes/ No

9. Counselling and advise 1. Family welfare and immunization activities

Yes/ No

2. Counselling for HIV/STD if available

Yes/ No

Signature or Signature of MO/ Para medic Thumb impression of beneficiary


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Annexure 5.1: Empanelment criteria for hospitals

Criteria for empanelment of Public Health Care Providers All Government hospitals as decided by the State Government (including Community Health Centres) and Employee State Insurance Scheme

hospitals shall be empanelled provided they possess the following minimum facilities

a. Telephone/Fax, b. An operational pharmacy and diagnostic test services, or should be able to link with the same in close vicinity so as to provide ‘cashless’

service to the patient. c. Maintaining of necessary records as required and providing necessary records of the RSBY patients to the Insurer or his representative/

Government/Nodal Agency as and when required. d. A Bank account which is operated by the health care provider through Rogi Kalyan Samiti or equivalent body.

Criteria for empanelment of Private Health Care Providers The criteria for empanelling private hospitals and health facilities would be as follows:

a. At least 10 functioning inpatient beds or as determined by State Nodal Agency. The facility should have an operational pharmacy and diagnostic test services, or should be able to link with the same in close vicinity so as to provide ‘cash less’ service to the patient.

b. Those facilities undertaking surgical operations should have a fully equipped Operating Theatre of their own. c. Fully qualified doctors and nursing staff under its employment round the clock. d. Maintaining of necessary records as required and providing necessary records of the insured patient to the Insurer or his representative/

Government/Nodal Agency as and when required. e. Registration with Income Tax Department. f. Telephone/Fax.

IT Infrastructure needed for empanelment in RSBY a. Both public and private health care providers which fulfil the criteria for empanelment and are selected for empanelment in RSBY by the

Insurance Company or their representatives will need to put in place infrastructure (hardware and software) as per requirement b. The Insurer shall be responsible for providing and installing the entire IT infrastructure (i.e., hardware and software) for each public

Empanelled Health Care Provider in a district before commencement of enrolment in that district. c. Each private Empanelled Health Care Provider will be responsible for providing and installing the entire IT infrastructure (i.e., hardware

and software) before commencement of enrolment in the district where such Empanelled Health Care Provider is located.

It is the responsibility of the hospitals to ensure that the system is running at all times and to inform the concerned SCSP/TPA which has installed the

system, in case there are any problems related to it’s proper use as required.


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Annexure 5.1 (a): Hardware specifications for hospital and PHC’s

The following are the hardware and software specifications for hospitals and PHC’s where wellness checks can also be carried out.

► Depending on RSBY turnaround sufficient number of desktops or laptop systems with dual core processor with 2 GHz, 80 GB hard disk drive, DVD

R/W drive, 2 GB RAM, graphics card, minimum 4 USB ports etc.

► Other software environment shall be as below:

a. Centralized TMS software b. Licensed MS windows 7 Operating System 32/ 64 bit or above

c. Microsoft.NET Framework 3.5 or above d. MySQL database, ODBC connectivity e. Microsoft crystal reports

f. Drivers for all the peripherals (printer, fingerprint scanner, smart card reader etc.)

► Printer (laser/dot matrix/inkjet etc.)

► Finger print scanner (one with each computer system) – One biometric fingerprint recognition device to be connected to desktop through USB port

with the following configuration:

a. 5v DC 500mA (supplied via USB port)

b. Operating temperature range: 0c to 50c

c. Operating humidity range: 10% to 90%

d. Compliance: FCC home or office use, CE and C-Tick

e. 500 dpi optical fingerprint scanner (22 x 24 mm)

f. USB 1.1 or above interface

g. Drivers for the device should be available on windows or Linux platform

h. Should provide PNG image as well as templates as per ISO 19794 and Minex format

i. Capable of converting fingerprint image to RBI approved ISO 19794 and Minex template

► Smart Card reader (two for each computer system) – two smart card readers with the following configuration:

a. PCSC and ISO 7816 compliant

b. Read and write all microprocessor cards with T=0 and T=1 protocols

c. USB 2.0 full speed interface to PC with simple command structure

► Internet connectivity for data transfer to SNA, central server etc.

► Externally powered USB hub with minimum 4 ports


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Annexure 5.1 (b): Hardware specifications for hospital and PHC’s

The following are the hardware and software specifications for tablets to be used in hospitals and PHC’s where wellness checks can also be carried

out in the event that desktop/laptop are not available.

S. No. Hardware description for tablet PC Specifications 1 Processor Cortex A8-1GHz 2 RAM 512 MB 3 Internal memory 4 GB 4 Memory (expandable) 32 GB 5 LCD screen 7 inch 6 LCD resolution 1024 x 600 7 Touch sensitivity Resistive/capacitive 8 Operating system Android 4.0 (ICS) 9 Video HD 720p 10 Battery Lithium polymer 4000 mAH 11 Battery life 4 hours 12 USB ports 2 Nos 13 Micro SD card slot 1 Nos

14 Wi-Fi connectivity Available 15 Bluetooth connectivity Available 16 3G dongle connectivity Available (external) 17 TV connectivity HDMI 18 Camera 3 MP 19 Audio jack 3.5 mm 20 MIC Inbuilt 21 Documents supported DOC, DOCX, XLS, XLSX, PPT, PPTX, Adobe flash 10.1 support 22 Audio format MP3, WMA, AAC, AMR, m4a, mp2, off, WAV, 3gp, 3gpp 23 Video format MPEG2, MPEG4, AVI, FLV, 3GP, MOV, DIVX, WMV

24 Multimedia display PNG, JPG, BMP, TIFF and GIF display 25 Adaptor 5V, 2A 26 Operating temperature 0 degrees Celsius to 50 degrees Celsius


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27 Storage temperature -20 degrees Celsius to +70 degrees Celsius 28 Weight 400 gms 29 Dimension 203 x 120 x 12 mm

Other specifications at PHC:

a. Other software environment will be as below:

i. PHC “wellness check” software

ii. Sqlite database

iii. Drivers for all peripherals (printer, fingerprint scanner, smartcard reader)

b. Printer (laser/inkjet etc.)

c. Finger print scanner (one in each desktop/laptop/tablet PC system)

d. One biometric fingerprint recognition device to be connected to desktop/laptop/tablet PC through USB port with the following

configuration:

i. 5V DC 500mA (supplied via USB port)

ii. Operating temperature range: 0 degrees Celsius to 50 degrees Celsius

iii. Compliance: FCC Home or Office use, CE and C-Tick

iv. 500 dpi optical fingerprint scanner (22 x 24 mm)

v. USB 1.1 or above interface

vi. Should provide PNG image as well as templates as per ISO 19794 and Minex format

vii. Capable of converting fingerprint image to RBI approved ISO 19794 and Minex template

e. Smart card reader (two for each desktop/laptop/ tablet PC system) – two smart card readers with the following configuration

i. PCSC and ISO 7816 compliant

ii. Read and write all microprocessor cards with T=0 and T=1 protocols

iii. USB 2.0 full speed interface to PC with simple command structure

f. Internet connectivity for data transfer to SNA, central server etc.

g. External powered USB hub with minimum 4 ports


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Annexure 5.2 Triggers for audit of hospitals

S. No. Triggers Remarks

1 RSBY admissions exceeding the registered bed strength of the hospital.

Refer the empanelled form/ information collected

2 Patient blocked/ transacted for discipline not available in the hospital.

Refer the empanelled form/ information collected

3 Same type of transactions happening / blocking of claims happening during fortnight.

The claim data to be analysed and flagged.

4 The claim transaction pattern different from the transaction pattern of the district.

The transactions of other hospitals with similar infrastructure to be matched.

5 Claim/ transactions with gender disparity Claims/ transactions which can only happen in females are blocked for male patients and vice versa

6 Claims/ transactions with age specificity Claims / Transactions are blocked for procedures which are unusual for a particular age.

7 All High value procedures above INR 15000 All high value transactions are high end procedures and require infrastructure and specialist services and needs to be investigated and verified.

8 Patient blocked for Hysterectomy - vaginal and abdominal

Commonly abused procedure

9 Patient blocked for Caesarean Section Commonly abused procedure

10 Patient blocked for Cholecystectomy and GB procedures.

Commonly abused procedure

11 Patient blocked for multiple procedures.

12 Use of frequent over ride codes for patient authentication.

This facility is commonly misused.

13 Any organ removal - cataract, appendix, GB etc.

To match the URN for past procedures if any.

14 Unusual increase in number of transaction Atleast more than 25 percent of average admissions per day for the hospital

15 Locality specific pattern of admissions To match the claims with area at backend.

16 Frequent Inter district claims / blocking To check the catchment of the hospital


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S. No. Triggers Remarks

17 Unusual increase in number inter district claims/ blocking

18 Blocking of Blood transfusion. To check whether the hospitals follows NBTC guidelines.

19 Frequent breakdown of software and hardware To check for tempering.

20 Transaction on hot listed card.

21 Similar pattern of admission and claim blocking

Say - blocking all medical admissions for 3 days

22 Patient blocked for ICU for more than 7 days

Annexure 6.1: Claim Rejection Reasons and codes under RSBY

The Insurance Companies receives the claims from hospitals through electronic data. The claims should be settled within 30 days of the receipt.

While rejecting claims, insurance company should select the reasons from the drop down. List of frequently used reasons along with reason codes are

listed down below:

S. No. Code Reject Reason

1 R0001 Data not uploaded within 7 days of transaction (transaction done within 24 hours of discharging patient).

2 R0002 Data not uploaded within 7 days of transaction and also Transaction not done within 24 hours of discharging patient.

3 R0003 Transaction not done within 24 hours after discharge

4 R0004 Patient stay in hospital is >24 hours (It is not a Day care package).


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5 R0005

Normal pre and postsurgical expenses are included in package. Hence General ward/ICU shall not be payable in continuation and prior

to Package. Payment for this service is included in the payment of major package blocked on the same day/admission. (Extending

patient beyond of LOS of surgical package requires written intimation with the TPA/ Payment for this service is included in the

payment for a related service performed on the same day.)

6 R0006 No investigation brief, indications of admissions, disease description, and line of treatment mentioned with package blocked.

7 R0007

The surgery package blocked is already included in previous major surgery blocked. It is the utilization of multiple codes, require

additional information/ similar procedure done in same admission and this is not justified. Hence claim not admissible. (mention the

first major package)

8 R0008 Registering, Blocking, Discharging transactions in 0 LOS.

9 R0009 Registering, blocking, discharging transactions in ___ duration for Day Care procedures

10 R0010 During the course of investigation it reveals that the hospital involves in the practice of charging money to patient. (TPA will confirm

it).

11 R0011 Patient and hospital admission documents (medical documents, registration of patient in admission register etc.) not found in hospital

of URN and package blocked. (If patient is not present at the time of visit, check with case file).

12 R0012 Procedure done does not match the diagnosis.

13 R0013 Rejected as deficiency of medical documents (specify the kind medical documents required, basis also).

14 R0014 Duplicate claim – twice uploaded for same Hospitalization

15 R0015 Hospital was found to be involved in a major fraud.


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16 R0016 Claims rejected in case of policy exclusions.

17 R0017 Member not enrolled.

18 R0018 Patient not required hospitalization.

19 R0019 OVERWRITING / MALPRACTICE

20 R0020 FP/BCP code Mismatch

21 R0021 Age/Gender Mismatch

22 R0022 Directly Discharge from ICU

23 R0023 Claim Rejected under Hotlist Card

24 R0024 Rejected as deficiency of medical documents (specify the kind medical documents required, basis also).

25 R0025 Rejected as the diagnostic package is blocked independently which is against RSBY guidelines

26 R0026 Rejected due to as per package list length of stay (LOS) is ------------- days but patient admitted & discharged in ------------- days

27 R0027 Rejected due to pre-Authorization was not taken prior to performing hysterectomy on patient below 40 yrs of age as per MOLE

guideline


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Apart from this a claim can be rejected on following grounds as well:

A. Fraud Related Reasons

1. During the course of investigation it is found that the hospital is involved in the practice of charging money from the patient even when the smart

card has balance left

2. Patient not found during hospitalization during a visit

3. The patient was not admitted & did not avail In-Patient treatment in the hospital

4. During Audit/Investigation Treatment not taken by patient proved and admitted

5. Unjustified blocking of higher-priced package(s) for the provided diagnosis

6. Connivance with beneficiaries for a claim without any ailment or treatment

7. Impersonation in connivance with cardholder

8. Procedure done does not match the diagnosis

9. Showing admission in ICU though treatment is being/was treated in general/ private wards.

10. The surgery package blocked is already included in previous major surgery blocked

11. Rejected due to patient directly discharged from ICU

12. Since minimum stay of 24 hours is required in the hospital by the patient, if the patient stay in hospital <24 hours (It is not a Day care package)

13. The disease/ailment is excluded in RSBY guideline

14. During investigation admission documents not found or incomplete in hospital

B. Policy Related Reasons 1. The pre-authorization was not taken prior to performing hysterectomy on patient below 40 years of age as per MOLE guidelines


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Annexure 7.1: Structure of Grievance Redressal Committee at district, state and national level

a. National Grievance Redressal Committee (NGRC):

The National Grievance Redressal Committee (NGRC) is formed by MoLE much before the commencement of the enrolment process with the following members:

1. Chairman - Additional Secretary (L&E), MoLE

2. Member – Joint Secretary & Chief Vigilance Officer, MoLE

3. Convener - Economic Advisor / Deputy Director in DGLW Office

4. NGRC may also invite other experts / officers for their inputs in specific areas.

5. NGRC may also take assistance of Director (Vigilance) and Director (RSBY)

6. The Additional Secretary or nominee, Department of Financial Services would be invitee to the NGRC meeting

b. State Grievance Redressal Committee (SGRC):

1. Chairman or his nominee (but not below the rank of Commissioner) - State Principal Secretary/Secretary of Department handling RSBY

2. Convener - State Nodal Officer for RSBY/ State Grievance Nodal Officer for RSBY

3. Member - State Representative of the Insurance Company (if more than one insurance company is active in the State, then one insurance

company may be selected for a fixed period on a rotation basis). IC should be represented by MD/CEO or their representative capable of making

financial decisions

4. Welfare Commissioner (in charge of the State), MoLE, GoI

5. The SGRC can also invite other experts / officers for their inputs in specific areas.


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c. District Grievance Redressal Committee (DGRC):

1. Chairman - District Magistrate or an officer of the rank of Addl. District Magistrate or his nominee or Chief Medical Officer ( if different than DKMA)

2. Convener - District Key Manager/ District Grievance Nodal Officer

3. Member - Representative of the Insurance Company, capable of making decisions

4. The DGRC can also invite other experts / officers for their inputs in specific areas

5. The DGRC shall meet once a month to resolve all grievances in the district

6. District Coordinator from insurance company to be included in the DGRC


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Annexure 7.2: Investigative Teams to support the grievance redressal committees at national and state level:

The investigative teams are to be set up at national and state level by MoLE to support the national and state grievance committees in resolving

grievances where extensive ground investigation activities are to be conducted before arising on a final decision.

a. National investigative team

The following is the composition of the national investigative team

1. Government Officer of atleast Under Secretary level

2. Medical Officer (from Government / private sector) with atleast 10 years of experience

3. The NGRC may nominate another member to provide inputs on technical matters such as technology, actuarial science, legal etc. He may be

nominated on a case by case basis

b. State investigative team

The state investigative team shall be nominated by the state grievance redressal committee (SGRC). The investigative teams will submit their report within 15 days of the grievance / complaint being given to them for investigation. The following is the composition of the state investigative team

1. Government Officer nominated by SGRC

2. Depending on the nature of grievance, SGRC can nominate any other person of technical, legal, actuarial and any other experience on a case by case basis. (from Government / private sector)


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Annexure 7.3: List of possible grievances / complaints for various categories

1. List of possible complaints / grievances pertaining to enrolment and action

S.

No.

Possible grievance / complaint Type

1 Smart Card not prepared despite name in the list Complaint

2 Registration money collected but enrolment not done , photographs taken but card not given on the spot Complaint

3 Additional money demanded apart from registration fees for issuance of card Complaint

4 Poor quality smart card given /Hospital List not provided with the Smart card Complaint

5 Card given to someone by enrolment team /and the person is demanding money to return card Complaint/ Grievance

6 Enrolment team returned back without doing enrolment, enrolment team did not turn up for enrolment Complaint/ Grievance

7 Kiosk not functional/ closed Complaint/ Grievance

8 Operator at Kiosk demanding money for addition and doing modification in card/ issuance of duplicate card or

splitting of card.

Complaint/ Grievance

9 FKO not present at the time of enrolment Complaint/ Grievance

10 DKMA demanding money for certifying enrolment Complaint/ Grievance

11 District and block level exercises for enrolment preparatory activities not done Complaint/ Grievance

12 Enrolment teams not reaching on time Complaint/ Grievance

13 Overpromise by the IA/ TPA regarding deployment of number of enrolment teams and kits/ enrolment kits not

Complaint/ Grievance


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S.

No.

Possible grievance / complaint Type

deployed as planned

14 Non deployment of District personnel /absence of District personnel of Insurer of Insurer Complaint/ Grievance

15 Villages not visited and left out by the enrolment team Complaint/ Grievance

16 Adequate publicity not done for mobilization of beneficiaries. Complaint/ Grievance

17 Signed data / FKO data or Post enrolled data not provided on time Complaint / Grievance

2. List of possible grievances / Complaints pertaining to empanelment of hospitals

S. No. Possible grievance / complaint Type

1 Hospital not empanelled Enquiry

2 Hospital has applied online, but not empanelled. Enquiry

3 Hospital applied online, recommended by District committee but still not empanelled

Possible reasons:

District committee list is not received at State Nodal Agency (SNA)

MHC cards are not received:

SNA has not sent request for MHC cards

Cards area not generated

Cards have been received at SNA but have not been given to the hospitals MOU between the hospital and Insurance company is not signed.

Hardware is not available

Transaction software is not installed

Grievance


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4 Hospital was part of RSBY network but not empanelled for the current round Grievance

5 Hospital complaints about in appropriate practices for empanelment Grievance

6 Hospital suspended/ De-empanelled during last policy period but not empanelled despite District committee

recommendations

Grievance

7 Hospital kept on watch list for no obvious reasons Grievance

8 Hospital suspended citing unusual claim transactions Grievance

9 Hospital suspended citing non adherence of MOU clauses Grievance

10 Hospital suspended citing Fraud and malpractices hospital Grievance

11 Hospital suspended following Fraud and malpractices reported in a hospital by new paper Grievance

12 Hospital suspended without following process Grievance

13 Hospital suspension following unsatisfactory reply to show cause notice Grievance

14 Hospital suspended but suspension not revoked even after 30 days.

1. Investigations by insurance companies not conclusive

2. Investigation not completed by Insurance company

Grievance

15 Hospital De- empanelled Grievance

16 Hospital complaint - inappropriate practices by the Insurance company and harassment. Grievance


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3. List of possible grievances / Complaints pertaining to Claims settlement and action


1 Claim details / payment details not received Complaint

2 Delayed payments Complaint

3 Claims rejected without giving reasons Complaint/Grievance

4 IA asking for Case/ patient records for claim settlement Complaint

5 Pending payments Grievance

6 Claims rejected on flimsy grounds. Grievance

7 IC/ TPA demanding money or incentive for claim settlement Grievance

8 Claims rejected by IC - URN not found, chip serial number mismatch Grievance


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Annexure 8.1: Basic infrastructure for kiosk to provide services to RSBY beneficiaries

The insurance company will setup and operationalize the district/ block kiosk in all the project districts within 15 days of signing the contract with the

state government.

1. Location of the district kiosk: The district/block kiosk is to be located at the district/block headquarters at a place frequented and easily

accessible. The state government will provide a place at the district/block headquarters to the insurance company to setup the district/block

kiosk. It should be located at a prominent place which is easily accessible and locatable by beneficiaries. Alternatively, the insurance company can

setup the district kiosk in their own district office. Sitting and waiting space, utilities, and water facilities for the beneficiaries to be ensured.

2. Specifications of the district kiosk: The district/block kiosk should be equipped with at least the following hardware and software (according to

the specifications provided by the Government of India),

Hardware components for district and block kiosk27:


Computer / Desktop PC

(1 in number)

► This should be capable of supporting all other devices required.

► It should be loaded with standard software as per specifications provided by the MoLE.

Configuration:

Desktop with dual core processor with 2 GHz, 80 GB hard drive, DVD r/w drive, 2 GB RAM, graphics

card, minimum of 4 USB ports etc.


Fingerprint Scanner /

Reader Module

(1 in number)

► Thin optical sensor

► 500 ppi optical fingerprint scanner (22 x 24mm)

► High quality computer based fingerprint capture (enrolment)

► Preferably have a proven capability to capture good quality fingerprints in the Indian rural

environment

► Capable of converting fingerprint image to RBI approved ISO 19794-2 template.


27

The hardware specifications provided is an indicative list and are subject to change depending on the decisions taken


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► Preferably Bio API version 1.1 compliant

Camera

(1 in number)

► Sensor: High quality VGA

► Still Image Capture: up to 1.3 megapixels (software enhanced)

► Native resolution is 640 x 480

► Automatic adjustment for low light conditions


Smartcard Readers (2 in

number)

► PC/SC and ISO 7816 compliant

► Read and write all microprocessor cards with T=0 and T=1 protocols

► USB 2.0 full speed interface to PC with simple command structure

► PC/SC compatible Drivers


Smart card printer

(1 in number)

► Supports Color dye sublimation and monochrome thermal transfer

► Edge to edge printing standard

► Integrated ribbon saver for monochrome printing

► Minimum printing resolution of 300 dpi

► Prints at least 150 cards/ hour in full color and up to 1000 cards an hour in monochrome

► Minimum Printing resolution of 300 dpi

► Compatible with Windows / Linux

► Automatic or manual feeder for card loading

► Compatible to Microprocessor chip personalization

► USB connectivity

► Printer with hardware/software protection to disallow unauthorized usage of printer

► Inbuilt encoding unit (ISO7816 and PCSC compliant) to personalize microcontroller chip

based contact cards in a single pass

► Smart card printing ribbon as required

District kiosk

Fingerprint scanner

► The fingerprint capture device at enrolment as well as verification will be single finger type

► Compliance with “fingerprint_image_data_standard_ver.1.0” mentioned on

www.egovstandards.gov.in. All specifications confirming to ”Setting level 31” will be

applicable for RSBY related enrolment and verification

► The images should be stored in .png format


Power backup ► UPS of capacity 860VA or higher

► Minimum 8 hours of power backup for specified hardware set


Telephone Line (1 Nos.) ► This is required to provide support as a helpline District and block kiosk

http://www.egovstandards.gov.in/


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Internet Connection ► This is required to upload/send data/ access the web based software for RSBY District and block kiosk

Master Kiosk card ► The card issuance system should be able to personalize a 64 KB NIC certified SCOSTA smart

card for the RSBY scheme as per the card layout.


Software components:

Software components Remarks District / block kiosk

Operating System

Vendor can adapt any OS for their software as long as it is compatible with the software

Suggestive software is: MS Windows 7 operating System 32/64 bit or above


System Software

The software for RSBY shall be provided by MoLE. Any updates and modifications shall be done with

instructions from MoLE.

The SCSP must ensure that the updated stand-alone software is provided to the kiosk operator

within 5 business days of the update.



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Annexure 8.2: Format for information display on hoarding / information board at kiosk

a. Facilities available at kiosk

b. Benefits under RSBY

c. Process of hospitalisation

d. Beneficiary rights

e. Do and don’ts for beneficiaries


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Appendix – I:

a. Roles and responsibility: Each individual officer / designate or department/ agency at the Central / State / District teams will hold a specific set of

responsibilities. The following describes the roles and responsibilities for each department/ agency / individual at the Central / State / District:

i. Ministry of Labour and Employment (MoLE):

► Issuance and periodic revision of guidelines benefits thereof for the scheme.

► Develop and provide qualifying criteria for empanelment and selection of different agencies like Insurance Company (IC), Third Party

Administrator (TPA), and Smart Card service Providers (SCSP), Audit agencies, IT agencies for software development etc.

► Develop RFP template for different process under RSBY

► Provide and support development of IT applications and software’s for the programme implementation like enrolment software, transaction

software, kiosk software, DKMA software etc.

► Develop Memorandum of Association (templates) between different stakeholders which can be used by the State Government and Insurance

Companies.

► In consultation with the States, development of such protocols and common standards as may be necessary to ensure effective functioning of the

RSBY scheme on a national basis. This would include determination of the protocol for national unique identification numbers for beneficiary

families, specification of the minimal technical standards of the smart card, ensuring timely transfer of the Central financing share of insurance

premium, establishment of common reporting protocols for states as part of scheme monitoring and such other design and implementation issues

considered necessary for the functioning of a coherent national system.

► Organizing periodic inter-ministerial meeting for coordination and convergence.

► Receive the beneficiary data from the state nodal agency (SNA) and checking it for internal consistency and duplication, generate URN, and

upload and map the approved data on the website within 7 days of receiving such data to the selected IC / SCSP.

► Receive the proposal from the SNA after they have selected the Insurance Company and place it before the Approval and Monitoring Committee

within 7 days of receiving such proposals from the SNA.

► Provide DKM and FKO cards within 7 days of receiving the request from the SNA along with the format for maintaining the record of these cards.

► Facilitate the appointment of District Information Officers (all selected districts for RSBY implementation) for selected CKGA functions as well as

upload and flow of DKMA data.

► Provide central contribution towards the premium for both new and renewal policy (if any) districts. The premium may vary between districts

during the year but the contribution and commitment for the premium shall be as per the following formula in consonance with Insurance Act,

1938. i.e. calculated as 75% of (X-60) + 60 (X being the premium amount per family).

► For both new and renewal set of districts, contribute premium as per the formula mentioned above to the insurance company selected for that

district.


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► Develop indicative package rate list and quality improvement parameters for RSBY hospitals.

► Develop training modules for different process and conduct TOT programmer for different stake holders.

► Provide technical guidance and assistance to the State Government and State Nodal Agency from time to time.

► Set up and monitor the functioning of National RSBY Toll free help line/call centre.

► Setting up of Complaints and grievance redressal management system (CGRMS).

► Setting up and functioning of National Grievance Redressal Committee (NGRC).

► Setting up and functioning of Program/ Technical Management division for - which would provide expert inputs to Central and State Governments

on matters pertaining to the design, implementation and monitoring/evaluation of the scheme implementation including external assistance and

cooperation.

► Organize National level reviews and conferences.

Conduct periodic reviews for monitoring the progress made in the project.

Commissioning short term evaluations, as well as special investigations as and when required.

i. State Nodal Agency (SNA): ► Identification of Districts to be taken up in for implementation of RSBY.

► Prepare BPL / other RSBY category data in the prescribed format as provided on the RSBY website www.rsby.gov.in conforming to

specifications laid down by Planning Commission for each project district and send the same to MoLE for internal consistency checking.

This process should be completed for the district before the scheme is launched. MoLE will upload the data on the RSBY website

(www.rsby.gov.in) after verifying the data and generating Unique Relationship Number (URN) for each target family.

► Advertise/tender for selection of Insurance Company for each of the identified districts as per the RFP document available on

www.rsby.gov.in. Only MoLE empanelled Insurance companies will participate in the tender.

► Form a committee for technical and financial bid evaluation. Committee shall have a Government nominee and may include technical

experts. Both the technical and financial evaluation shall preferably be done on the same day.

► Send the proposal in the prescribed format to the MoLE where it will be placed before the Approval and Monitoring Committee (A&M).

Once the proposal is accepted and approved by the committee SNA shall commence the implementation process.

► Prepare a contract document (MCA) to be signed with the selected Insurance Company (ies) based on the draft contract document

provided on the RSBY website www.rsby.gov.in.

► Appoint a District Key Management Authority (DKMA) for each of the identified districts. The SNA shall convey the details of the DKM to

MoLE at the earliest for issue of DKM card by CKGA.

► Providing DKMA Server including Smart card readers and fingerprint scanners at district headquarter within 10 days of signing of the

agreement with the IC.




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► Install DKMA software for issue of FKO cards and for downloading of data subsequently from FKO cards and uploading on central web

application.

► Set-up and staff State Nodal Agency (SNA) to implement the scheme in the State. The Nodal agency shall be appropriately staffed as per

GOI communications to carry out its functions effectively in implementing the scheme. This should be a separate legal entity under the

control of the state government. Most of the responsibilities of the state government could be executed by the SNA.

► Set up and staff district level offices for effective implementation of RSBY in the district. The district level units in addition to the DKMA

will house additional staff for assistance and better coordination.

► Constituting and conducting of interdepartmental meetings on a periodic basis (monthly) consisting of representatives of at least Labour,

Health and Rural Development Ministries in the state.

► Organize a state-level workshop wherein the MoU between Central and State Government will be signed. Preferably the Contract between

State Government and Insurance Company (ies) shall also be signed in this workshop.

► Provide assistance to the SCSP in the registration of beneficiaries and issue of smart cards by:

Identifying and appointing District Key Managers (DKM) before signing of the agreement with the insurance company and convey

the details to the Central Government within 5 days of signing the agreement with the insurance company.

Providing DKMA Server at District Headquarter within 7 days of signing of the agreement with the insurance company. Install

DKMA software for issue of FKO cards and for downloading of data subsequently from FKO cards.

Nominating Field Key Officers (FKO) in the required prior to commencement of enrolment. The FKO numbers shall be identified at

the time of signing of the agreement with the insurance company. (FKOs will jointly visit each enrolment station along with the

SCSP representative for the enrolment of the beneficiaries)

Receive DKM and FKO cards from MoLE and maintain the records of it in the web based application as well as in the format

prescribed by the SNA.

► Assist the insurance companies and SCSP in organizing district-level Workshops and ensure that all related officials participate in the

workshop.

► Provide support and assistance to the SCSP through the district and block level officials in the issuance of smart cards in the village by:

o Finalizing village-wise schedule with the SCSP.

o Helping to publicise the visit of the enrolment team in advance.

o Support in identifying location for the enrolment inside the village

o Ensure presence of nominated official FKO for authenticating cards at the time of issue.

► Retain Rs. 30/- collected from the beneficiary as registration fees for meeting administrative expenses in implementing the scheme at the

state.

► Make available the public health care facilities, such as district hospital and Community Health Centres (CHCs), for being considered for

‘network’ hospitals by the insurance company.


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► Ensure that sufficient number of hospitals have been empanelled before start of the enrolment of beneficiaries in the concerned district.

This may be done with the help of the district level officials.

► Ensure that the district and block kiosks are set up in each of the project districts/ blocks and are operational before the commencement

of the enrolment process in the district. Request the district administration to provide space for the district / block kiosks in a government

designated place which is easily accessible and well recognised. The SCSP may be asked to pay rent for the space provided.

► To ensure that the public hospitals are equipped with necessary hardware and software to enable transactions in the hospital through the

smart card. (These should be PC based systems as defined in Annexure-5. Identify at least two personnel in each hospital who would be

trained by the insurance company representatives to man the RSBY help desk at the hospital and ensure that the insurance company or

their representative provides training to these personnel about RSBY, usage of hardware and software at the hospital and conduct

transactions.

► Commitment for 25% contribution of the premium and for incurring the administrative costs. Procure the necessary approvals from the

concerned state departments to ensure timely flow of state contribution towards the premium as per the defined formula in consonance

with Insurance Act, 1938.

► Ensure timely release of premium of state share to the insurance company.

► Request MoLE for the release of central share of premium within 5 days of releasing state share of premium to the insurance company,

through the web based application.

► Transfer the central share of the premium to the insurance company within 20 days of the receipt of the amount from MoLE.

► Provide financial and technical support to the district level RSBY offices.

► Take necessary steps for improving the awareness level by organising different activities like health camps etc. through Civil Society

organisations/ NGOs/ experts to improve awareness and to facilitate access to health services.

► Putting in place mechanisms for incentivizing staff at various levels like FKO, hospitals, etc. to improve both enrolment, wellness check

and utilization.

► Facilitate, monitor and evaluate the implementation of the scheme as per the guidelines issued from time to time by MoLE and any

additional guidelines the state government itself shall adopt from time to time in relation to the scheme.

► Organize periodic review meetings with the Insurance Company to review the implementation of the scheme.

► Access the data from central server at MoLE to analyse data and MIS reports for monitoring implementation of the scheme and

performance of various stakeholders.

► Conduct evaluation of RSBY performance in the State. The process of selection of agencies for doing this independent evaluation and

tools involved therein has been provided on the RSBY website www.rsby.gov.in.

► Provide timely information, either directly or through the web application / in prescribed format as desired by MoLE from time to time.

The required information and the reporting format shall be intimated by MoLE.



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► Ensure resolution of complaints at state level by involving the insurance company, hospital or any other stakeholder against whom the

complaint has been filed.

► Participate in grievance redressal and ensure that SGRC report is available to NGRC and MoLE for resolution of grievances escalated to

NGRC.

ii. District Key Manager (DKM):

► A person of class -1 rank is designated as the District Key Manager (DKM)

► DKM may delegate additional authority, of equivalent rank, to work on his behalf or during his absence. Such an official will be known as

the Additional DKM.

► DKMA will send request to CKGA through SNA in a prescribed format for number of required Field Key Officer (FKO) cards.

► DKMA will receive the required number of cards from the CKGA through SNA.

► DKMA will be responsible for the safe custody of the cards in a safe place under a vault (or lock and key arrangement), and shall keep an

account of these cards through manual procedures as well as on the web based application.

DKMA would personalize and issue the FKO card after obtaining proper receipt from FKOs according to the specified schedule. The

data of issuance of cards will be stored on the DKMA computer automatically by the software and can be tracked. FKO card

personalization is done by using data and fingerprint of the designated FKOs stored in the database on the DKMA computer. In

case of change of FKOs, the DKM should re-personalize the card for new FKOs.

► DKMA will ensure upload of data from the FKO cards and retain the FKO cards post completion of enrolment process.

► Facilitate and coordinate the working of district RSBY committee for empanelment of adequate number of hospitals as well as ensure that

reputed hospitals are also empanelled, besides organizing periodic reviews for monitoring the progress of scheme implementation.

► Personalize and issue key cards to the hospitals and authorize the hospitals for RSBY transactions.

► As Member convener of District level grievance redressal committee, ensure regular meetings and compliance of directions issued.

► Provide space or make arrangement for establishment of district/ block kiosks and monitor its operations.

► Personalize and issue key cards to the kiosk and authorize the kiosk for operations.

► Support the insurance companies for organizing district level workshops and FKO training.

► Carry out awareness activities for enrolment and utilization of services under the scheme.

iii. Field Key Officer (FKO): The responsibilities of FKO can be categorized under pre-enrolment, enrolment and post enrolment phases.

Pre-enrolment activities:

► Receive personalized Master Issuance Card (FKO card) from the DKM after providing the fingerprint.


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► Receive information about the name of the village (s) and the location of the enrolment station inside the village where the FKO will

perform the enrolment.

► Receive the contact details of the SCSP or their field agency representative for enrolment process.

► Keep track of the date on which enrolment has to take place.

► Reach the enrolment station at the given time and date (Inform the SCSP and DKM a day in advance in case the FKO is unable to come)

► Ensure that the FKO card is personalized with his/ her details and fingerprints and is not handed over to anyone else at any time during

enrolment and post enrolment.

► Should ensure that at least 1 card for every 300 beneficiaries, expected at the enrolment camp, is issued to him i.e., in case the BPL list

for a location is more than 300, they should get more than 1 FKO card personalized with their details & fingerprint and carry with them for

the enrolment.

Post enrolment activities:

► Ensure that the BPL list is displayed at the enrolment station

► Identify the beneficiary at the enrolment station either by face or with the help of identification document (Can also make use of the Gram

Pradhan or any other person to correctly identify the beneficiary).

► Make sure that the enrolment team inputs the correct name, gender and age data of dependents in the field in case of any mismatch with

the already provided data.

► Make sure that the enrolment team is not ‘willingly’ excluding any member of the identified and verified BPL households for RSBY

enrolment.

► Immediately after card is printed, the FKO should validate the card by inserting his/ her smart card and provide his/her fingerprint for

personalizing the beneficiary card.

► Make sure that the enrolment team is issuing the smart card on the spot to the beneficiary.

► Make sure that the enrolment team is collecting only Rs. 30 from the beneficiaries and also issuing the beneficiary a receipt of the same

along with the card.

► Ensure that the details of all eligible (within RSBY limits of Head of family + spouse + 3 dependents) family members as per BPL list and

available at the enrolment station entered on the card, their fingerprints & photograph taken and recorded on the beneficiary card.

► Ensure that the enrolment team is providing a brochure to each BPL family along with the smart card

► Ensure that the smart card is given inside a plastic cover and beneficiaries are explained not to laminate it. The FKO should also ensure

that the national toll-free number is printed on the card cover provided to the beneficiary along with the card.

► If a beneficiary complains that their name is missing from the BPL list then make sure that this information is collected in the specified

format and shared with the district administration.


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► If all dependents of a beneficiary, eligible for enrolment are not present at the camp, they should be informed that a request for addition

to the card can be made at the district/block kiosk.

Post enrolment activities:

► Return the FKO card(s) to the DKM after the enrolment is over at the location(s) for which the FKO is responsible.

► At the time of returning the card, ensure that the enrolment data is downloaded from the card and that the number of records

downloaded is the same as the number verified at the enrolment camp. In case of any discrepancy, the difference should be conveyed to

the DKM and the card be sent to CKGA for technical resolution.

► Furnish a brief report of the enrolment process to the DKM along with a signed undertaking.

► Hand over the list of left out people, collected at the enrolment camp to the DKM.

► Receive the incentive from the State Government (if any).

iv. Insurance Company (IC):

► Enter into agreement with other insurance companies working in RSBY regarding usability of the same smart card across India at any of

the networked hospital. This will ensure that beneficiary can use his/ her smart card across India to get treatment in any of the

empanelled health care providers.

► Set up state and district level offices for RSBY implementation and coordination.

► The insurance company will necessarily need to complete the following activities before the start of the enrolment in the district:

Empanelment of adequate number of hospitals in each district

Printing of the booklets which is to be given to the beneficiaries with the smart cards or requisite information for the booklet is

provide to the SCSP for printing these booklets.

Ensuring availability of policy number for the district prior to enrolment.

Ensuring that the correct addition of insurance policy details and policy dates, i.e., start and end dates, to the central server.

Ensuring that contact details of the nodal officer of the Insurer, the nodal officer of the TPA and the nodal officer of the service

provider are updated on the RSBY website.

► Ensuring that hospitals adhere to the agreements as per RSBY guidelines.

► Send data related to hospitalization, claims raised, settled and paid and other aspects of the scheme to the central and state government

at periodic intervals (on a monthly basis as well as when desired).

► Take immediate remedial action on beneficiary feedbacks/complaints and update the results on the web application for reference of state

government/nodal agency/MoLE.


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► The Insurer will be responsible for ensuring that the functions and standards outlined in the RFQ for empanelment are met, whether direct

implementation rests with the Insurer or one or more of its partners under service agreements. It shall be the responsibility of the Insurer

to ensure that any service agreements with the organizations outlined above provide for appropriate recourse and remedies for the

Insurer in the case of non- or partial performance by such other organizations.

► Ensure that the hospitals are raising claims within 7 days of the discharge of the beneficiary.

► Capture the facilities and treatments provided by the empaneled hospitals and publish the same on the RSBY website post this data has

been verified by MoLE.

► Update the packages as and when revisions take place in the procedures and convey the changes to SNA and MoLE within 3 days of

making the change.

► Manage and the empanelment and de-empanelment process for hospitals and monitor hospitals on a regular basis.

► Empanel another hospital within the area in the event of de-empanelment of hospital to maintain the number and spread of hospitals.

► Adhere to the SLA’s for claim settlement and payment to hospitals.

► Participate in periodic reviews and coordination meetings of SNA and Districts.

► Participate in state and district level grievance committees.

► Provide requisite training to SNA, DKM, SCSP and hospital staff pertaining to policy and system usage.

► Provide IEC activities post enrolment for beneficiaries, by ensuring detailed hoardings/ information boards at the empaneled hospitals.

v. Smart card service provider (SCSP): ► To provide a route map to the SNA, DKM and FKO prior to commencement of enrolment process

► To manage and drive the enrolment process by enrolling maximum beneficiaries

► To manage and operate the district/block kiosk

► To provide, install and maintain the smart card related infrastructure at the public hospitals. They would also be responsible for training all

empanelled hospitals on the RSBY policy as well as usage of the system along with the IC.

► Provide for Annual Maintenance Contract (AMC) of the equipment supplied at public hospitals and PHF’s.

► Facilitate field audit at enrolment stations and hospitals on a regular basis.

► Provide IEC and BCC activities, especially for the enrolment process (prior to commencement of enrolment).

vi. Hospitals or Health Care Providers:

► Private hospitals shall ensure that the requisite hardware is procured and functional prior to applying for empanelment under RSBY.

► Ensuring cashless treatment to the RSBY beneficiary.

► Display status of being an empanelled provider of RSBY in the prescribed format given by State Nodal Agency outside/ at their main gate.


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► Provide a functional help desk for giving necessary assistance to the RSBY beneficiaries. At least two persons in the hospital will be

nominated by the hospital that will be trained in different aspects of RSBY and related hardware and software by the insurance company

and SCSP.

► Display the RSBY information poster near the reception/admission desks along with the other materials supplied by the insurance

company for the access of beneficiaries. The template of empanelled status and poster for reception area will be provided by the SNA.

► Present claims on the insurer electronically through the web based application. The empanelled health care providers shall avoid making

manual claims.

► Update hospitalisation data of RSBY patients electronically on a daily basis such that it reflects in the central server.

► Maintain such records and documentation as are required for the insurance company to pre-authorise treatments and process claims.

► Cooperate with the insurance company and the SNA and provide access to all facilities, records and information for the conduct of audits

or any other performance evaluations of the performance by the empanelled health care provider.

► Comply with the provisions of all applicable laws, statutes, rules and regulations, as amended from time to time.

vii. Public health facilities / Center (PHF / PHC): ► Provide pre-designed basic wellness check for the enrolled RSBY beneficiaries as per the format mentioned in Annexure 4.1 (a).

► Ensure that basic wellness check data is stored on the card of the beneficiary before he leaves the PHC.

► Display and provide information about the facilities available free cost at the wellness check centre.

► Provide treatment to the common ailments to the beneficiaries.

► Provide counselling services about health conditions to the beneficiaries.

► Upload data on basic wellness check to central server.

viii. Welfare Commissioner:

► The data of the beneficiaries is to be updated once in six months. It is the responsibility of the welfare commissioner to coordinate with the

respective departments in the state for providing the MoLE/SNA with updated data of all beneficiaries.

► The welfare commissioner shall also extend his support to the SNA during the data collection process / pre-enrolment stage by ensuring

timely receipt of data from the state departments for the enrolment process.

ix. District Informatics Officer (DIO):

► The DIO shall be responsible to personalize the DKM card received from MoLE ensuring that all the details of the DKM have been stored

(including biometrics).


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x. District/ block kiosk:

► The kiosk shall provide RSBY services such as modification / updation, card split (at district), card replacement (at district) to the

beneficiary.

► Upload the transaction data on the central server if done through the stand-alone module.

► Submit request for enrolment in RSBY by a beneficiary to the SNA.

► Enter complaints/ grievances from the beneficiaries on the CGRMS.

xi. Role of Pensioners

Since RSBY is being implemented at grass root level i.e. Panchayats/block/ward level there are large number of retired civil and defence

pensioners at these locations. It is felt that their services can be utilized in various ways for benefit of the beneficiaries.

The Registered Associations for civil pensioners and pensioners who have retired from defence/para military forces at

district/panchayat/ward level could be engaged by the SNA for the services. The SNA would decide the qualification of pensioners to be

engaged as per their requirement. An honorarium could be paid to pensioners by SNAs out of administrative expenses through Registered

Associations of the Pensioners based on the criteria of payment of honorarium to the Block Level Officers (BLO) by the Election

Commission.

The pensioners could perform following functions:

► Awareness generation amongst the target groups about their eligibility, process of enrolment and guiding them at the

enrolment stations.

► During the enrolment, guide them to nearest PHC/ hospital for wellness checks.

► Ensure that the beneficiaries are informed by the stakeholders about any change in the enrolment schedule/extension in

policy end, if any.

► Assisting the beneficiaries at empanelled hospitals and educating them at the hospital to avail the benefits

► Facilitate the beneficiaries in the registration and discharge process in the hospital

► Surprise visits to hospitals/enrolment stations to collect feedback from the beneficiaries in the format designed by SNA

RSBY Revised Process Guidelinesrsby.gov.in/Docs/Revamp of RSBY Phase II- Process...RSBY Revised...

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Transcript of RSBY Revised Process Guidelinesrsby.gov.in/Docs/Revamp of RSBY Phase II- Process...RSBY Revised...