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Claims Adjudication

Manual | a

Claims Adjudication Manual

Ayushman Bharat

Pradhan Mantri Jan Arogya Yojana (PM-JAY)

National Health AUTHORITY

February 2019

Table of Contents

ACRONYMS ........................................................................................................................................................................ 5

1. ABOUT AB PM-JAY ..................................................................................................................................................... 6

2. PURPOSE OF MANUAL .............................................................................................................................................. 7

3. BASICS OF ADJUDICATION ...................................................................................................................................... 7

4. TARGET TURN- AROUND-TIME ................................................................................................................................ 9

5. ROLES & RESPONSIBILITIES ................................................................................................................................... 9

6. END TO END WORKFLOW......................................................................................................................................... 11

7. PROCESS FLOWS ....................................................................................................................................................... 12

7.1. Pre-authorization Process. .................................................................................................................................... 12

7.2. Claims Processing ................................................................................................................................................. 15

7.3. Review by Accounts Officer and Payment by SHA/IC ........................................................................................ 20

7.4. Reconsideration of Rejected Claim. ..................................................................................................................... 20

7.5. Claims Audit for Quality Check ............................................................................................................................. 21

8. COMPLICATED CASES .............................................................................................................................................. 21

8.1. Leave Against Medical Advice (Lama)/Discharge Against Medical Advice (DAMA) ........................................ 21

8.2. Mortality Case ........................................................................................................................................................ 21

8.3. Unspecified Surgical Cases .................................................................................................................................. 22

8.4. Portability Cases .................................................................................................................................................... 23

8.5. Enhancements and Partial Payments .................................................................................................................. 24

8.6. Unbundling of Procedures..................................................................................................................................... 24

8.7. Treatment Beyond Sum Insured/ Available Wallet .............................................................................................. 25

8.8. Payment in Case of Hybrid Model ........................................................................................................................ 25

ANNEXURE 1: EXCLUSIONS TO THE POLICY/SCHEME ............................................................................................ 26

ANNEXURE 2: template – OT NOTES, CLINICAL NOTES, DISCHARGE CARD AND CLINICAL PHOTO ........... 27

Claims Adjudication Manual | 3

Acronyms

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6 | Claims Adjudication Manual

2. Purpose of Man ual

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6. End to En d Wor kflow

Pre-authorization Initiated

by MEDCO/PMAM

Response to query

Case Auto-approved for Case requiring manual

listed procedure approval from PPD

Raise Query

tat 6 hours

Rejected Approved

Treatment provided and

patient discharged by PMAM

tat 15 days

Claim updated and claim

initiated by PMAM

Response to query

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CPD/Trust/ Insurance

Raise Query

tat 15 days

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Accounts Officer

IC/ SHA Approval (if

mandatory)

Claim settlement


7. Pr cess F lows

7.1. Pre-author ization Process

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Please refer to Approver’s Ma nual for detailed infor mation on the above:

https://w ww.pmjay.gov.in/site s/default/fil es/2018-12/Approvals %20_User_ Manual_v2.0.pdf


Actions to be taken by PPD on a Pre-auth orization r equest (TA T: 6 Hours)

Surgical /

Medical Package Enhancement of

Medical Package

Auto Approval Without Auto

Approval

PPD’s bucket

Assigned to

Entitlement Check

Validate beneficiary details (name, age, sex

etc.) mentioned in the Pre-auth form against

the ones stored against PM-JAY id

Documents Review

PPD shall ensure:

- All mandatory documents are uploaded - Symptoms & diagnosis are in sync - Diagnostic reports conclude the diagnosis - Package requested is in sync with diagnosis

Investigation and Audit

If required, the case would be sent for

investigation

Assigned to

Another PPD/

Medical Committee

Approve/ Reject/

Query

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7.1.2. D ocuments review

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7.1.3. Pre-authoriza tion Approval/Rejecti on

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7.2. Claims Processing

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Actions to be taken on a claim by CEX & CPD:

Submitted Claim

CEX bucket

Claim Executive (CEX)

Non-Technical review:

- Confirm upload of mandatory documents - Confirm upload of all package specific

documents

- Match beneficiary’s bed side photo with

the one saved against PM-JAY id

CPD bucket

Claims Panel Doctor (CPD)

Technical review of documents

- Symptoms & diagnosis are in sync - Diagnostic reports conclude the diagnosis - Package requested is in sync with diagnosis - Post surgery reports confirm that

the booked surgery was performed

Investigation and Audit

If required, the case would be sent

for investigation

Assigned to

Assigned to Another CPD/

Medical Committee

Approve/ Reject/

Query

Claims Processing Timeline

Successful submission

Treatment of claim - 15 days

Time

Patient admitted Patient Claim

discharged successfully

for treatment

from hospital submitted

Time spent in claims and accounts

department - 15 days

Claim validated

Claim Payment

by CEX & CPD


7.2.1. N on-Technic al Docume ts Review

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7.2.4. Claim Appro al/ Rejecti on

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7.3. Re view by Account s Officer and Pay ment by SHA/IC

Appr ved claims :

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Forward

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forward

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CPD Hospital

7.4. Re conside ration of Rejected Claim

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dical Advic (DAMA)

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