Registration FAQ's

• Q1. What is Registration ?
  Registration is the process involving collection of data about new patients to start generating a medical record.
• Q2. Who will do the registration in hospital ?
  A facilitator called Aarogyamithra will be available in the hospitals to register, facilitate the treatment and guide you for all the services.
• Q3. How can I recognize Aarogyamithra ?
  Aarogyamithras are provided with uniform with a scheme related logo on the apron for easy identification and placed at Aarogyasri/EHS kiosk, a special help desk situated at reception in the hospital.
• Q4. What are the services provided by Aarogyamithra ?
  Receive the patient
  Verify the health card / documents of the patients.
  Obtain digital photograph of the patient.
  Facilitate the Patient for consultation and admission
  Preliminary diagnosis
  Counsel the patient regarding treatment/surgery.
  Facilitate hospital send proper pre-authorization.
  Follow-up preauthorization procedure and facilitate approval
  Follow-up recovery of patient.
  Facilitate discharge of the patient.
  Obtain feedback from the patient.
  Counsel the patient regarding follow-up.
• Q5. Once the registration is done by aarogyamithra, where should the patient go?
  Aarogyamithra will facilitate your registration,admission and treatment in the hospital.
  MEDCO, an identified doctor in the hospital will facilitate online approvals and treatment in the hospital.
  Hospital will provide separate OP and IP wards(Private & Semi Private) in each specialty for EHS patients.
• Q6. Who will do the preliminary diagnosis in the hospitals ?
  MEDCO is the person responsible right from the point of raising the e-preauthorization request till the settlement of claim.
• Q7. What are the services provided by Medco ?
  Diagnosis
  E-Preauthorization,
  Feedback on the patient's condition and services offered by the hospital during hospital stay of the patients,
  Discharges, deaths if any,
  Follow-up,
  Free consultation of the patients and distribution of medicines after discharge etc.,
• Q8. What if, the patient is found to be suffering from 'listed therapies' ?
  If the patient is found to be suffering from listed therapies, MEDCO shall submit the preauthorisation through the Trust portal within 24hrs.
• Q9. What if, the patient is found to be suffering from diseases that are not covered in listed therapies and which cannot be managed in NWH ?
  Such patients shall be counseled and referred to nearest suitable hospital for further management.
• Q10. On what basis , patient is evaluated as IP/OP ?
  Based on the investigation reports, patient will be evaluated as IP/OP.
  
  OP consultation: Patient is forwarded to OP and investigations facilities are prescribed. Once investigation is done and if the patient is to be treated as OP case, prescription is given. Diagnosis and prescription are entered in the system by NAM and the case gets disposed thereafter.
  
  IP consultation: If the patient treatment warrants the use of any listed therapies, Medco enters the details of the procedure and investigations in the system, converts the case to IP and raises authorization.
• Q11. What are the responsibilities of the hospitals while treating the patient under the scheme ?
  The responsibilities of the hospitals include:
  
  Separate OP
  Patient registration
  Initial evaluation (diagnostic tests) related to identified diseases
  Identification of disease
  Out-patient prescription
  Admission of in-patients
  Sending pre-authorization for surgery / treatment
  Obtaining approval for surgery
  Treatment / surgery
  Free food during hospitalization
  10 days post discharge medication
  Follow up services for one year for identified diseases under the scheme
• Q12. In case if the diagnostics prescribed is not available in the hospital, then what needs to be done by the patient ?
  The hospital will guide the patient to the tied up diagnostic center, wherein the diagnostic center will do the investigations free of cost.
• Q13. Do I get any registration slip and registration Number ?
  Yes, after online registration, Aarogyamithra will provide 'patient registration form'.
• Q14. Where can I get information about the Scheme ?
  You can get information on the scheme by calling round the clock call center through toll free number 104 or by approaching Aarogyamithra in any of the hospitals nearer to you.
• Q15. What will happen in case Aarogyamithra is not available in the hospital ?
  You can call round the clock call center works with the help line No. 104.
• Q16. Whom should I meet in case of emergency ?
  Aarogyamithra, in case if Aarogyamithra is not available he/she can meet MEDCO or Duty doctor.
• Q17. Does Aarogyamithra be available round the clock ?
  NAMs are appointed by the Trust and available round the clock to attend to patient registration, consultation, diagnostic services, pre- authorization, discharge and follow-up.
• Q18. Should I need to pay for investigations in the hospital ?
  No, As per scheme guidelines the hospital should perform the investigations free of cost.
• Q19. Should I need to pay money for registration ?
  No.
• Q20. How can I avail the benefits under the scheme in case of accidents & emergencies as I may not carry Health Card ?
  In case of emergency admission and if treatment is covered under the scheme in that Network Hospital, 48 hours time will be given to you to produce health card. You shall register with Aarogyamithra in the hospital to avail the services. You may call toll free number 104 to guide you to the nearest network hospital.

Preauthorisation FAQ's

• Q1. What is Preauthorisation ?
  Preauthorization is the sanction process given to the hospital by trust for an inpatient treatment. Medco will upload all the necessary documents of the patient and send the case to trust for preauthorisation approval.
• Q2. Is there any formal approval needed to perform surgery ?
  Yes, Preauth requests are to be scrutinized as per the guidelines issued by the Trust.
• Q3. What is the turn around time for getting a preauth approved ?
  Monitoring on regular basis for clearance of pre-authorisations in TAT(Turn Around Time) i.e., in 12 hours.
• Q4. Is it necessary for the patient to get approval for preauthorisation ?
  Yes, only after getting the preauthorisation approval, the hospital will perform surgery/treatment.
• Q5. In case if the treatment cost is exceeding 2lakhs what will happen ?
  In such scenario, the cases will be directed to CEO for additional financial assistance and only on approval of CEO, the surgery/treatment can be performed.
• Q6. In case if a preauth is rejected can it be reconsidered ?
  The rejection of preauth by Trust shall not be construed as refusal of treatment to the patient by the Trust. The rejection of preauth merely means the disease of the patient and the treatment choices are out of listed therapies.
• Q7. In case if the preauth approval doctor's opinion is differed from treating doctor, then will I get approval for preauthorisation ?
  In case of difference of opinion, Final decision on pre-authorizations will be exercised by 'scheme technical committee' which have powers to directly recommend to CEO.
• Q8. In case if a hospital is not empaneled for the treatment required to the patient, then will the hospital get approval ?
  The patient needs to be stabilized and referred to near by EHS empaneled hospital where the specialty is available.
• Q9. Can a hospital apply for more than one treatment ?
  Yes, The hospital can apply preauthorisation for more than one treatment.
• Q10. In case, if a patient needs multiple procedures in a single sitting then will that be possible ? Yes, the hospital can apply multiple procedures in a single sitting.
• Q11. What happens if the treatment cost exceeds the package amount ?
  The hospital has to apply for enhancement of package.
• Q12. How many levels are there for getting a pre auth approval ?
  The preauthorization requests are scrutinized as per guidelines issued by the Trust at three levels
  
  a. Scrutiny by pre-auth executive for first level.
  b. Scrutiny by specialist for second level approval
  c. Scrutiny by Trust doctor for final approval within 12 hours of submission of request by NWH.
• Q13. Is there any enhancement provision available in the scheme ?
  Yes, There is provision for enhancement in the scheme.
• Q14. In case, if the patient has come on emergency then what is the process of getting preauth approval ?
  For such emergency cases, Telephonic Emergency Approval will be taken. NWH shall obtain emergency telephonic pre-authrorisation through dedicated round the clock telephone lines of the Trust, if the patient is suffering from listed therapies. Please click here to know the Telephonic intimation process.
• Q15. Is there any TAT for registering telephonic approval cases ?
  Telephonic cases submitted by preauth executive should be auto canceled if no action has been taken within 72 hrs.
• Q16. Shall I need to pay the hospital if my initial tests do not confirm the identified disease under the scheme ?
  No. Even after initial tests, if the disease is not confirmed, you need not pay the hospital, as initial evaluation for identified diseases is free under the scheme
• Q17. How can I proceed if initial medical tests conducted suggest that I am not suffering from any of the identified diseases ?
  After free initial evaluation if it is found that the disease is not covered under EHS, either you can approach any government hospital or you may continue treatment in the same hospital on payment for further treatment.
• Q18. Will I be provided with food in the hospitalization?
  Yes. You will be provided food during hospitalization as part of treatment under the package.
• Q19. Can I get information on type of specialty services available in the hospital ?
  You can get information on the type of specialty services through toll free number 104. You can also contact Aarogyamithra at network hospital nearer to you for information.
• Q20. Will I be getting quality treatment under the scheme ? If so how is it ensured by the Trust ?
  Yes. Trust ensures quality treatment is provided to the patient by
  
  i. Providing facilitator services at the hospital.
  ii. Stringent empanelment procedure and quality control measures.
  iii. Disciplinary actions against erring hospitals.
  iv. Pre and post treatment online evaluation by specialist doctors.
  v. Round the clock call centre to register complaints.
  vi. Medical audit mechanism.
  vii. In-house vigilance checks on hospitals.
  viii. Elaborate field mechanism.
  ix. Social auditing through feedback letters from beneficiary.
  x. Formulation and implementation of technical and administrative guidelines from time to time.
  xi. Grievance redressal.

Claims Processing FAQ's

• Q12. When the claim should be initiated once the patient is discharged ?
  Network Hospital will raise the claim from 11th day onwards after satisfactory discharge of the patient upon the performance of the listed therapy.
• Q13. Do the hospital need to submit the original bills by hand or through courier ?
  No, not required. All Claims processing (claim initiation, collection of documents, scrutiny of claim documents) shall be carried out electronically through the Trust Portal.
• Q14. What are the documents which needs to be submitted at the time of claim ?
  The hospital needs to submit case sheet scanned copy, patient bill and any other investigation reports or evidences the hospital thinks that it will be useful for processing of claims. These documents should be uploaded in the portal while submitting the claim.
• Q15. Do the Govt pay for failed procedure ?
  Yes, the Trust will pay for failed procedures also, there are certain guidelines issued for all such procedures.
• Q16. Can I raise a claim if the patient is died after surgery ?
  Yes, The hospital can raise claim for the patients who are died after conducting the surgery or in the course of treatment.
  Guidelines are issued for these cases.
  In case of death within 24 hours of surgery (1st post-op day), 75% of package amount will be paid.
  In case of death after 1st post-OP day, 100% claim will be paid.
  In case of death during pre-operative period, no claim will be paid.
• Q17. What is the claim settlement process for medical cases in case of death ?
  In case of death within few days / hours, claim settlement will be based on per day cost of service center.
• Q18. In case of multiple surgeries in a single sitting what is the procedure for payment of claims ?
  For procedure having high package will get 100 % and for secondary procedure the hospital will get 50 %.
• Q19. In case if there are two surgeries performed for the patient during one hospitalization, then what is the procedure for payment of claims ?
  For procedure having high package will get 100 % and for secondary procedure the hospital will get 50 %
• Q20. If the patient requires any additional investigations after the surgery, so the hospital gets additional money for investigations ?
  No, the hospital have to absorb the cost in the package only, The hospital can not raise claim for additional investigations nor they can collect money from patient.
• Q21. How do the hospitals receives money once the claim is honored ?
  The claims payments will be credited directly to the Hospital Bank Account through Online Bank Transfer.
• Q22. What is the time span for the settlement of claims ?
  The Claim shall be settled and payment made to the NWH within 7 days.
• Q23. Are there any time lines for claim processing ?
  The following are the time lines for processing of claims.
  i. Claim submission:
  90 days from the date of discharge of patient.
  ii. Surgeries/ Treatments:
  The Service Provider shall perform surgeries/ treatments within 30 days from the date of expiry of the contract for all the pre-authorisations.
  iii. Responding to queries of trust
  a. NWH shall reply within 7 days from the date of query provided.
  b. 90 days has not lapsed from the date of discharge.
  iv. Eligible claims to be paid by the Trust:
  a. Trust shall make payments within 7 working days subject to submission of all the supporting documents.
  b. Cumulative processing time : Less than 60 days.
  c. If it crosses 60 days : The claim deemed as approved.
  v. Failure to update pending remarks by NWH:
  15 days notice through online and claims submitted stands forfeited.
  vi. Appeal time: Within 30 days from the date of forfeiture of Claims.
• Q24. How many levels of verification shall be performed as soon as claim is submitted ?
  Four levels of verification shall be performed:
  a. Scrutiny by claim executive for first level.
  b. Scrutiny by specialist for second level.
  c. Scrutiny by trust doctor for third level.
  d. Scrutiny by JEO/claim head for fourth level.
• Q25. What is the additional time provided to NWH in case a claim is sent back for clarification ?
  An additional time of 7 days will be allowed in case of claim is sent back to the NWH for clarification.