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Directorate (Medical) Delhi

Employee’s State Insurance Corporation,

5th& 6th Floor (Admin Block), ESIC Hospital Complex, Basaidarapur,

New Delhi-110015

Website: www.esic.nic.in, www.esichospitals.gov.in

“Notice Inviting Expression of Interest (EoI) for Empanelment of Hospitals for Super Speciality

Treatment Services”

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EoI No.111-U/17/11/15/SST/Med. II -Vol.IV Dated: 22.05.2020

Expression of Interest (EoI) NOTICE Empanelment of Hospitals for Super Speciality Treatment Services

Online EoI are invited by the Director (Medical) Delhi, Employees’ State Insurance Corporation, 5th& 6th Floor (Admin Block) ESIC Hospital Complex Basaidarapur, New Delhi-110015 through e-procurement portal of https://eprocure.gov.in/eprocure/app from the interested and eligible hospitals in the catchment areas (approx. 25 Km)of ESIC Hospitals of Delhi (Rohini, Basaidarapur, Jhilmil & Okhla), Noida, Sahibabad, Gurugram, Manesar and Faridabad for providing super specialty Treatment to entitled ESIC Beneficiaries including Staff & pensioners of ESIC in Delhi/ NCR on cashless basis for 02 years extendable for another 01 year with mutual consent as per need. (Instructions regarding online bid submission can be referred from Annexure- “E” of EoI Document)

Last date of submission of

EoI online

Date & Time of pre-bid meeting Date & Time of opening of the

online EoI on CPPP

Date:24.06.2020

Time: 02:00 PM

Mode of Pre-bid meeting will be

virtual (application based/email).

Details will be communicated

through corrigendum/publishing

on ESIC website/CPP Portal, kindly

keep visiting ESIC website/CPP

Portal for updation.

Date: 25.06.2020

Time: 02:30 PM

EoI along with all terms and conditions and procedure of EoI may be view ed online or

downloaded, by the bidder from the website- https://eprocure.gov.in/eprocure/app,

https://www.esic.nic.in/tenders and http://www.esichospitals.gov.in.

All bidders are requested to check further notifications/updates if any, on the above-mentioned web sites.

DIRECTOR (MEDICAL) DELHI

Directorate (Medical) Delhi 5th& 6th Floor (Admin Block)

ESIC Hospital Complex Basaidarapur, New Delhi-110015

E-Mail ID: [email protected] Website: www.esichospitals.gov.in

Phone: 011-28334604, 011-28334830

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Application Form

(For empanelment of Hospitals for Super Speciality Treatment)

To, The Director (Medical) Delhi, Directorate (Medical) Delhi, 5th& 6th Floor (Admin Block), ESIC Hospital Complex, Basaidarapur, New Delhi-110015. Subject: -EoI for Empanelment for Super Speciality Treatment to ESI Beneficiaries including staff & pensioners of ESIC. Sir/Madam, In reference to your advertisement in the website/CPP Portal dated__________________, I/we wish to offer the super speciality services available in our organization as accredited by NABH/NABL for ESI beneficiaries including staff & pensioners of ESIC on cashless basis. NOTE: Hospitals will offer all the services facilities/specialties (under super Speciality) for which it is NABH/NABL accredited. I/We pledge to abide by the terms and conditions of the EoI Document and I/We also certify that we understand the consequences of default on our part, if any.

(Name and signature of the Proprietor/Partner/authorized person)

Place: Date: Enclosures: Duly filled Annexure along with enclosures & transaction receipt.

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(Please read all terms & conditions carefully before filling the application form and annexure thereto)

1. INSTRUCTIONS TO SERVICE PROVIDERS FOR SUBMISSION OF Expression of Interest (EoI)

a) Document Cost & EMD: - The EoI Document can be downloaded from the Central Public Procurement Portal (CPPP) at https://eprocure.gov.in/eprocure/app, & http://www.esic.nic.in/tenders. Application form shall accompany non-refundable fee of Rs. 1,000/- (Rupees One Thousand Only) and EMD of Rs.1,00,000/- (Rupees One Lakh Only). The bidder has to pay the above said amount Rs. 1,01,000/- {I.e. Rs. 1,000+ Rs.1,00,000 (Application fee & EMD)} through online mode (RTGS) only. Bank Details as below: - Account Name : EMPLOYEES STATE INS CORP Bank Name & Branch : State Bank of India, Najafgarh Road, New Delhi-15 Account No. : 10304101068 IFS Code : SBIN0001181 MICR No. : 110002079 Note 1: - The Transaction report generated online including UTR number must be uploaded with application form. Note 2: - Application received without online Application fee and EMD will not be evaluated. Application fee and EMD received through Bankers Cheque/ DD will not be admissible and such EoI will be summarily rejected.

b) Document Acceptance: - The bidders have to apply online with all annexure and necessary documents as per checklist through Central Public Procurement Portal (CPPP) for ESIC on NIC at https://eprocure.gov.in/eprocure/app. Only online documents and annexures will be considered for evaluation.

c) Please ensure that each page of the EoI is downloaded. The documents as per checklist

(Annexure-C) is to be signed, stamped by the Proprietor/Partner/Authorized Person (Due authorization to be enclosed, in case of authorized person) and scanned and uploaded online.

d) The Hospitals are advised to go through the Instructions for Online Bid Submission annexed at Annexure-E and ensure that all documents required to be uploaded are legible.

e) EoI document/application will be out rightly rejected if any technical condition is not

fulfilled.

f) On being selected for empanelment, before entering into MoU the Hospitals shall have to furnish the following Performance Security Deposit in the form of Bank Guarantee from a scheduled commercial bank having validity of 03 years (i.e. 01 year beyond the expiry of contract). Hospitals (Single/Multi Super Speciality) Rs. 10,00,000/- (Rupees Ten Lakhs Only) Stand alone Dialysis Centres Rs. 2,00,000/- (Rupees Two Lakhs Only)

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Note: All scanned documents being uploaded should be ensured to be duly filled (if required) /signed and stamped compulsorily by authorized signatory.

g) The scope of services for empanelled hospitals will be as follows:

Super Specialty Services: -

NOTES:

Some of the above mentioned facilities are available in-house in some ESIC hospitals and referrals will be made on actual need basis only. The above list is not exhaustive and other Super Specialities Services as per requirement may be outsourced. Hospitals shall offer only the services facilities/specialties which are NABH/NABL accredited but in case any indoor ESIC beneficiary needs any other services then the treatment should be provided with due permission of the Competent Authority at CGHS/State Govt. rates.

ELIGIBILITY CRITERIA

Essential eligibility requirements: -

a) The Hospitals must have a valid NABH/NABL accreditation as applicable. Copy of NABH/NABL accreditation along with scope of services shall be enclosed.

b) The super specialty hospitals shall have at least 100 bed capacity. The hospital is required to have at least 10 bedded ICU.

c) In case of empanelment for single super specialty Hospital such as exclusive nephrology/oncology/cardiology/neurology/dialysis centre etc. the bed strength criteria will be 50 beds or more.

Cardiology CTVS (Cardiothoracic vascular Surgery) Nephrology including Renal Transplant Urology Plastic Surgery Endocrinology Medical Oncology (Chemotherapy) Onco Surgery Radio Therapy Neurology Neuro Surgery Dialysis Paeds Surgery Paeds Cardiology Paeds Cardiac Surgery Gastroenterology GI Surgery Vascular Surgery Organ and Tissue transplant

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d) Dialysis: Multi-specialty hospital (100 Bedded or more) with in-house dialysis facility (Dialysis bed not less than four with at least one for Sero positive patients) shall be preferred over exclusive dialysis centre.

e) Exclusive dialysis centre: Exclusive dialysis center (50 Bedded or more) should be under the supervision of nephrologists and preferably with ICU services will be empanelled (exclusive dialysis centres to be empanelled will be decided on the basis of referral load and the centres having more number of dialysis machines will be preferred.)

(NOTE: The number of beds as certified in the Registration Certificate of State Government/Local-Bodies/NABH/Fire Authorities/Pollution control authorities shall be taken as the valid bed strength of the Hospital). f) The Hospital should have been operational for at least one complete year as on

31/03/2020. The audited balance sheet, profit and loss account for the financial year (2018-19) should be submitted as proof of being in business. For those Hospital who have completed 01 year of existence as on 31/03/2020, may submit provisional balance sheet, profit and loss statement duly certified by director and auditor.

g) The Hospitals located in Delhi must have minimal annual turnover of Rs. 2

crores and those located in other cities of NCR must have minimal annual turnover of Rs. 1 crore. Exclusive Dialysis center, annual turnover of Rs. 20 Lakhs for centres located in Delhi & Rs. 10 Lakhs for Exclusive Dialysis centers located in other cities of NCR.

h) Valid State registration certificate/registration with local bodies should be attached.

i) Valid Fire clearance certificate should be attached. j) Valid compliance with all statutory requirements of waste management. k) 24 hrs Emergency services managed by technically qualified staff. l) Provision of Dietary Services for indoor patients. m) Valid certificate of registration for Organ and Tissue Transplant Facilities,

wherever applicable. n) Hospitals having in-house Blood Bank should enclose valid license. o) Hospital should have in-house diagnostic facilities for providing Super

Specialty treatment. GENERAL CONDITIONS FOR EMPANELMENT

a) In the first instance, only the Hospitals empanelled with CGHS fulfilling the eligibility criteria will be empanelled without being subjected to inspection. In case sufficient number of CGHS empanelled NABH/NABL certified Hospitals with requisite bed strength are not found, other applicants will be taken into consideration after inspection.

b) In case sufficient number of CGHS empanelled Hospitals are not available in catchment area (approx. 25 Km i.e. shortest road distance up to 25 Km with acceptable 10% variation) of the listed ESIC hospitals, Hospitals empanelled with State Govt. will be empanelled without being subjected to inspection.

c) In case sufficient number of CGHS empanelled as well as State Govt. empanelled Hospitals are not available in catchment area of the listed ESIC hospitals, to meet the requirements, other Hospitals may be considered for empanelment after inspection by a team duly constituted by D (M) D, based

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on the additional information furnished in the Annexure ‘A’. The empanelment of such non-CGHS/non-State Govt. empanelled hospitals will be restricted only to the extent of short fall considering the specialty wise referral load. For short-listing of such hospitals, the NABH accredited specialities available, number of total beds, number of ICU beds, in-house diagnostic facilities etc. will be the criteria.

d) The application, if received, from the Institution which was de-empanelled by any ESIC /CGHS/Any Govt. institution will not be taken into consideration for one year from date of de- empanelment to date of submission of application.

e) The Hospital shall be empanelled for all Super Speciality services available in the health care organization (HCO) as accredited by NABH/NABL.

f) The Hospital shall agree for conducting Annual Health Check-up of the ESIC Group ‘A’ Officers of 40 years & above of age (including all investigations / diagnostic tests/ consultations etc. as specified by Govt. of India from time to time), subject to the conditions that the hospital shall not charge more than Rs. 2,000/- for conducting the prescribed medical examination of the male officers and Rs. 2,200/- for female officers of ESIC who come to the hospital/institution with the requisite permission letter.

g) An agreement on stamp paper of Rs.100/- shall be signed with the successful applicants and incidental charges related to agreement shall be borne by the empanelled centre. Agreement will be effective from the date of signing of the agreement.

h) The hospital should have the capacity to submit all the claims/ bills in electronic format to the ESIC System and must also have dedicated equipment, software and connectivity for such electronic submission.

i) ESIC has engaged UTIITSL as the bill processing agency for the scrutiny and processing of all bills of empanelled hospital and diagnostic centers for ESIC beneficiaries referred by ESIC competent authority (MS of ESIC Hospital, Rohini/Basaidarapur/Okhla /Jhilmil/Sahibabad/Gurugram/ Manesar/ Faridabad/ Director (Medical) Delhi/Director (Medical) Noida/ RD-Haryana/UP. Empanelled hospitals shall accept the terms and conditions related to online submission and processing of bills in the UTI-ITSL application/any other agency ESIC hires for bill processing and payment.

j) The empanelled centers for ESI Beneficiaries will also provide cashless Medical Treatment to the duly referred ESIC Staff and dependents (Serving &Retired) as per their entitlement.

k) In case of emergency admission, ESIC Beneficiaries may attend any tie-up hospital. For this purpose, ESIC beneficiaries should produce his/her ESIC identity Card to the concerned hospital. The concerned hospital will issue the “Emergency Letter “for the same and affix attested photograph of the patient and thereon obtain permission from D(M)D office/RD Office of respective state within 24 hrs of emergency admission via email and generate UTI Claim Id also. The DMD Office/RD Office will issue referral letter after verification and approve the same in UTI Module.

l) Patients visiting the empanelled hospital without proper referral letter shall not be generally eligible for cashless services. In case, an ESIC beneficiary (with valid ESIC Card and eligibility) reports to the hospital without proper referral documents and subsequent covering referral is also not received from the competent authority for such direct admission, he / she may be provided

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treatment on Cash basis at CGHS Rates, in case it is a dire life-threatening emergency and the patient’s condition would have severely deteriorated, if he/she had gone to ESI Hospital for referral.

m) ESIC reserves the rights to accept /reject one or all applications at any time without assigning reasons thereof.

n) “Force majeure” will be applicable to both the parties. o) Any medico legal issue arising out of treatment of patients under this

empanelment will be the responsibility of the empanelled hospital. p) Any difference or dispute arising during the period of empanelment will be

submitted for arbitration as per MoU. q) Courts at Delhi shall have the exclusive jurisdiction to deal with legal issues /

disputes arising out of the functioning of the empanelled hospital. r) The Hospital should give an undertaking accepting the terms and conditions as

detailed at Annexure-B of the EOI document.

TERMS AND CONDITIONS RELATED TO TREATMENT, PACKAGES AND RATES: -

a) The empanelled Hospital would be paid at CGHS rates, terms and conditions as adopted by ESIC Headquarters Office from time to time. Any additional guidelines/circulars issued by ESIC Headquarters Office from time to time shall also be applicable for the services provided by Hospitals under this empanelment.

b) Insured Persons and beneficiaries are entitled for General Ward. The staff (serving & retired) and their dependents are to be provided treatment/ services as per their entitlement (General Ward/Semi private/Private Ward).

c) “Package rate” shall mean and include lump sum cost of in-patient treatment /day care/diagnostic procedure for which ESIC beneficiary has been permitted from time of admission to the time of discharge, including (but not limited to) (i) registration charges (ii) admission charges(iii) accommodation charges including patient's diet (iv) operation charges (v) injection charges.(vi) Dressing charges (vii) Doctor/ consultant visit charges(viii) ICU/ICCU charges (ix) monitoring charges (x) transfusion charges (xi) anesthesia charges(xii) operation theater charges (xiii) procedural charges/ surgeon's charges/ surgeon's fee (xiv) cost of surgical disposable and all sundries used during hospitalization (xv)cost of medicines (xvi) related routine and essential investigations (xvii) Physiotherapy charges etc.(xviii) nursing care and charges for its services and all other incidental charges related thereto.

d) Package rates also include two pre-operative consultations and two post-operative consultations.

e) In case of surgical procedures, where its name is not listed under CGHS rate list, the rates given under other minor/major surgery under each specialty shall be applicable.

f) Cost of implants/stents/grafts is reimbursable in addition to package rates as per CGHS ceiling rates or as per actual, whichever is lower.

g) If there is no CGHS prescribed ceiling rate for any implant reimbursement shall be limited to 60% of the MRP including GST & Hospitals cannot charge more than that amount from ESIC & its beneficiaries. The pouches/stickers etc. attached should be duly verified by the treating doctor and the specifications should match with those mentioned in Discharge Slip and original

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receipt/invoice or attested photocopy of receipt/invoice in case of bulk purchase.

h) During in-patient treatment of the ESIC beneficiary, the hospital will not ask the beneficiary or his/her attendant to purchase separately the medicines / sundries / equipment or accessories from outside and will provide the treatment within the package rate, fixed by the CGHS which includes the cost of all the items, However, toiletries, sanitary napkins, talcum powder, mouth fresheners are not payable/ reimbursable.

i) In cases of conservative treatment, where there is no CGHS package rate, calculation of admissible amount would be done item wise as per CGHS/AIIMS rates. If there is no CGHS/AIIMS rate for a particular item, admissible amount would be 15% discount on empanelled Hospital’s rate-list submitted with the EOI. However, food supplements, toiletries and cosmetic items shall not be reimbursed.

j) Package rates envisage up to a maximum duration of indoor treatment as follows:

Upto 12 days for specialized (Super Specialties) treatment Upto 07 days for other major surgeries Upto 03 days for /Laparoscopic surgeries/elective angioplasty/normal deliveries and 01 for day care/ minor (OPD) surgeries. Short admission/OPD treatment for injections, infusion, etc. Rs. 500/- would be payable/reimbursable for all categories of beneficiaries. However, if the beneficiary has to stay in the hospital for his/ her recovery for a period more than the period covered in package rate, in exceptional cases, supported by relevant medical records and certified as such by hospital, the additional permission may be allowed, which shall be limited to accommodation charges as per entitlement, investigations charges at approved rates, doctors visit charges (not more than 2 visits per day per specialist / consultant) cost of medicines for additional stay). If more than one specialist is required to be consulted for treatment then the bills would be accepted only with proper justification of visits of different specialist.

k) Maximum duration of indoor treatment under package rate shall be as per CGHS. However if additional stay beyond the period covered in package rate is required for recovery, in exceptional cases, supported by relevant medical records and certified as such by the hospital, additional reimbursement shall be allowed for accommodation charges (as per entitlement), investigation charges (at approved rates), doctor's visit charges (not more than two visits per day by specialists/consultation and cost of medicine (10% discount on MRP) if prior permission has been taken from the referring authority. No additional charge on account of extended period of stay shall be allowed if that extension is due to any complication/consequences of faulty surgical procedure/ faulty investigation procedure etc.

l) Any legal liability out of such services shall be the sole responsibility of and shall be dealt with by the concerned empanelled hospital/centre.

m) The empanelled health care organization (HCO) cannot charge more than CGHS approved rates when a patient is admitted with valid ESIC card with prior permission or under emergency.

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n) If any empanelled health organization charges from ESIC beneficiary for any expenses incurred over and above the package rates vis-à-vis medicine, consumables, sundry equipment and accessories etc., which are purchased from external sources, based on specific authorization of treating doctor/staff of the concerned hospital and if they are not falling under the list of non-admissible items, that amount shall be recovered from the pending bills of hospitals.

o) In case, the hospital rates for treatment procedure/ test are lower than CGHS rates, the charges will be paid as per actual. The Hospitals to provide its complete rate list at the time of submission of EOI.

p) If one or more minor procedures forms a part of major treatment procedure, then package charges would be permissible for major procedure and only 50% of charges admissible for minor procedure.

q) If required, the empanelled hospitals should check the eligibility of the referred patients on the IP portal www.esic.in. In case of doubt, the advice from referring authority can be taken. The validity of the referral letter is for seven days from the date of issue. Patient attending the hospital beyond validity period should be asked to get the referral letter renewed/ revalidated.

r) All the drugs/dressings used during the treatment of the patient should be of generic nature as far as possible, and approved under IP/BP/USP/FDA Pharmacopoeia or on DGESIC or CGHS rate contract. Any drug/dressings not covered under any of these pharmacopoeias will not be reimbursed.

s) The tie-up hospital shall raise the bills on their hospital letter heads as per the terms and conditions of ESIC and UTI-ITSL. Efforts will be made by ESIC to make payments within prescribed time limit, once the bills are cleared by UTIITSL and hard copies of the bills received are in order. Incomplete bills in any form shall not be processed and may be returned for correction. Tie-up Hospital shall respond to queries raised by UTI-ITSL within the time frame as specified in UTI-ITSL module. The responsibility of nonpayment due to late response or no response will solely lie on the concerned tie-up hospital.

t) The empanelled hospital shall honor permission/referral letter(P1) issued by competent authority (MS of ESIC Hospital,Rohini/Basaidarapur/ Okhla/Jhilmil /Sahibabad/Gurugram/Manesar/Faridabad/Director (Medical) Delhi/Director (Medical) Noida/ RD-Haryana/UP, without delay and provide treatment/ investigation facilities as per referral format on priority basis. The tie up hospital will provide medical care on cashless basis as specified in the referral letter; no payment shall be made to tie-up hospital for treatment/procedure/ investigations which are not mentioned in the referral letter. If the tie up hospital feels the necessity of carrying out any additional treatment/ procedure/investigation in order to facilitate the procedure for which the patient was referred, the requisite permission for the same is to be taken from the referring authority either through e-mail, fax or telephonically (to be confirmed in writing at the earliest).

u) It shall be mandatory for tie-up hospital to send a report online of the cases admitted, as per the prescribed format to the MS concerned/ Directorate (Medical)Delhi/Directorate (Medical)NOIDA on the same day or the next working day after receipt of referral.

v) The specimen signatures of the authorized signatory (Nodal Officer nominated by the empanelled hospital) duly certified by the competent authority shall be

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submitted to all ESIC hospitals/Directorate (Medical) Delhi/Directorate (Medical) NOIDA and UTI- ITSL. The name and mobile number of the Nodal Officer should be displayed at the reception of the empanelled hospital. Any change in authorized signatory, shall be promptly intimated by the tie-up hospitals to all referring hospitals and Directorate (Medical) Delhi and UTI-ITSL.

w) The Director (Medical)Delhi/Medical Superintendent/Authorized Person may visit the empanelled Hospitals to check the quality of services and other necessary certification. The Tie-Up Hospital authorities shall co-operate in carrying out the inspection.

x) Only the drugs which are available in IP/BP/US Pharmacopoeia and approved by Drug Controller General of India shall be used for indoor patients. Preferably the drugs which are available in DGESIC/CGHS Rate contract shall be used. The anticancer drugs, for patients on day care treatment may be provided by ESIC (referring authority). Due demand for the same shall be raised through ESIC beneficiary well in advance. Specific conditions, if required, be also mentioned in the demand/ prescription. The chemotherapy drugs amount shall be paid as per Life Saving Drugs rate-list of CGHS. Imported brands shall not be used if Indian drugs are available.

y) The hospital must agree for implementation of EMR (electronic medical record) / EHR (electronic health record) as per standards notified by Ministry of Health and Family Welfare, Govt. of India within one year of their empanelment (if not already implemented).

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CRITERIA FOR DE-EMPANELEMENT

De-empanelment of the Hospital may be done due to any one of the following reasons:

a) Rendering unwillingness to continue in the panel.

b) Due to unsatisfactory services and proven case of malpractice or misconduct /

medical negligence.

c) Refusal of timely services to ESI beneficiaries.

d) Undertaking unnecessary procedure(s) in patients referred for IPD/OPD

management/ investigation purpose.

e) Prescribing unnecessary/untested drugs/tests while the patient is under

treatment.

f) Carrying out drug trials on ESI beneficiaries.

g) Persistent overbilling of the procedures/treatment/investigation(s) undertaken.

h) Reduction in number of full-time experienced consultants /

staff/infrastructure/equipments etc. after the hospital has been empanelled.

i) Non-submission of reports, habitual late submission or submission of incorrect

data in the report.

j) Refusal to provide cashless treatment to eligible ESIC beneficiaries.

k) If de-empanelled by CGHS or any other Govt. or Public Sector Organization.

l) If de-accredited for NABH/NABL at any stage after empanelment.

m) Discrimination against ESI beneficiaries vis-a-vis general patients.

n) Death of owner/ change of ownership, location of business place or the practice

place, as the case may be, if not approved by competent authorities.

o) If the owner gives the establishment on lease to any other agency without the

consent of ESIC.

Note: Once any Hospital is de-empanelled, the MoU with that hospital shall stand

terminated from the date of de-empanelment. Such hospital will be debarred for

empanelment for a period of one year. If the hospital is blacklisted, it will be debarred from

empanelment for a period of three years.

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2. PROCEDURE FOR REFERRAL: -

ESI Corporation has engaged UTI Infrastructure Technology and Services Limited (UTI-ITSL) as a Bill Processing Agency (BPA) for scrutiny and processing of all bills of empanelled hospital for beneficiaries referred from ESIC Institution through the online internet module, managed by BPA. The detailed procedure for referral has been laid down in the Standard Operating Procedures (SoP) of the said agreement which is annexed herewith as Annexure-F. The SoP as amended from time to time shall be applicable to MoU executed under this EOI.

3. PAYMENT SCHEDULE:

I. The Empanelled Hospital will send hard copies of bills along with necessary supportive documents(Form P1, PII, PIII & PVI as per Annexure-F to the referring center after due scrutiny by UTIITSL for payment enclosing therewith copy of the medical record of every patient, discharge slip incorporating brief history of the case, diagnosis, details of (procedure done, blood bank notes, treatment of Medicines given etc.), reports and copies of investigation done, identification of the patient, entitlement certificate, referral letter from concerned ESIC Institutions, original purchase invoice, stickers and envelops of implants, wrapper and invoice of drugs costing more than Rs. 5000/- and CD of treatment/procedure given shall be submitted by the Hospital along with the bill. Additionally, chronologically placed IPD notes/ Films (X-ray, MRI, CT Scan etc.)/ OT notes/ Pre and Post operation radiological images or any other documentary requirement can be sought if required.

II. Original procurement invoice of the stents/implant/device used in the procedure along with its outer packing and sticker must be enclosed with the bills submitted for payment duly verified by treating specialist and authorized representative of Hospital.

III. The procedures/ treatment/ investigation provided by the Super specialist/Specialist should be duly signed by the treating Super Specialist/specialist along with their stamp & Registration No.

IV. Each and every paper/ record, so attached with the bills so meant for ESIC should be signed by the authorized representative of the Hospital/ Diagnostic centers.

V. Above said documents shall be uploaded in the system in support of the claim, within 7 (seven) working days. Immediately after uploading the bills by Tie Up Hospital (TUH), UTI-ITSL would start processing the bills without waiting for receipt of hard copy of bills by ESI locations. UTI-ITSL would scrutinize the bill completely (including need more information steps) and recommend d admissible amount to ESI. This recommendation would be visible to referring locations including TUH’s, D(M)D Office & ESIC Hospitals.

VI. Once the empanelled Hospital receives information regarding the bills that have been scrutinized by UTI-ITSL, the empanelled Hospital will submit the original hard copies of such bills as per the dates of scrutiny in 4 distinct bundles to ESIC Hospitals/D(M)D Office.

a) OPD Bills with CGHS Codes. b) OPD Bills without CGHS Codes. c) IPD Bills with CGHS Codes. d) IPD Bills without CGHS Codes.

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VII. Depending upon the quantum, such bundles of bills be submitted to ESIC Hospitals/

D(M)D Office on weekly/ fortnightly/ monthly basis for receipt in UTI Module and further processing of payment.

VIII. After receipt of original bills, the ESIC Hospitals/ D(M)D office shall complete the scrutiny /process of payment to TUH as per the existing guidelines.

IX. The processing fee admissible to BPA will be at the rate of 2% of the claimed amount of the bill submitted by the empanelled hospital (and not on the approved amount) and service tax/GST/any other tax by any name thereon. The minimum admissible amount shall be Rs. 12.50 (exclusive of service tax/GST /any other tax by any name, which will be payable extra) and maximum of Rs. 750/- (exclusive of service tax/GST/any other tax by any name, which will be payable extra) per individual bill/claim. The fee shall be auto-calculated by the software and prompted to the ESIC Hospital by the system at the time of generation of settlement ID. The BPA processing fee will be borne by the empanelled Hospital by way of deductions from the admissible amount against their claims.

DUTIES &RESPONSIBILITIES OF EMPANELLED HOSPITALS:

a) It shall be the duty and responsibility of the hospital at all times, to obtain, maintain and sustain the valid registration and high quality and standard of its services and healthcare and to have all statutory/mandatory licenses, permits or approvals of the concerned authorities as per the existing laws.

b) There must be a prominent display with ESIC Logo with the words "We provide Cashless Treatment to ESI Beneficiaries on referral by ESIC. In case of difficulty please contact _______ (Names of Two Nodal officers)" by the empanelled Hospitals. The list of documents required to be carried by ESI patients/attendant must also be displayed.

c) The Hospital will not make any commercial publicity projecting the name of ESIC on Display board.

LIOUIDATED DAMAGES:

a) The Tie-up centers shall provide the services as per the requirements specified by the

ESIC in terms of the provisions of this Agreement. In case of violation of the provisions of the Agreement by the Hospital such as refusal of service or direct charging from the ESI Beneficiaries or defective service and negligence etc. the amount up to 15% of the amount of Performance Security will be charged as agreed Liquidated Damages by the ESIC. However, the total amount of the Performance Security will be maintained intact being a revolving Guarantee.

b) In case of repeated defaults by the tie-up centers, the total amount of Performance Security will be forfeited and action will be taken for removing the Health Care Organization (HCO) from the empanelment of ESIC as well as termination of this Agreement.

c) For over-billing and unnecessary procedures, the extra amount so charged will be deducted from the pending / future bills and the ESIC shall have the right to issue a written warning to the health Care Organization (HCO) not to do so in future. The recurrence, if any, will lead to the stoppage of referral to that particular Health care Organization (HCO) or De-empanellment from ESIC.

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PENALTY CLAUSE:

a) The agreement may be terminated by either party with one-month notice on either side.

b) In case of premature termination of contract/agreement by the empanelled Hospital without giving the required notice period of one month, Hospitals will have to deposit of Rs. 50,000/- (Rupees Fifty Thousand) in ESIC Fund Account No.1. If Hospital hesitates to deposit money the same will be deducted from security money/ incoming, pending bills.

4. INDEMNITY:

The Hospital shall at all times, indemnify and keep indemnified ESIC against all actions, suits, claims and demands brought or made against in respect of anything done or purported to be done by the Hospital in execution of or in connection with the services under this Agreement and against any loss or damage to ESIC in consequence to any Action or suit being brought against the ESIC, along with (or otherwise), Hospital as a party for anything done or purported to be done in the course of the execution of this Agreement. The Hospital will at all times abide by the job safety measures and other Statutory requirements prevalent in India and will keep free and indemnify the ESIC from all demands or responsibilities arising from accidents or loss of life, the cause or result of which is the Hospital negligence or misconduct. The Hospital will pay all the indemnities arising from such incidents without any extra cost to ESIC and will not hold the ESIC responsible or obligated. ESIC may at its discretion and shall always be entirely at the cost of the tie up Hospital defends such suit, either jointly with the tie up Hospital or separately in case the latter chooses not to defend the case.

5. ARBITRATION:

If any dispute or difference of any kind what so ever (the decision whereof is not being

otherwise provided for) shall arise between the ESIC and the Empanelled Center upon or relation to or in connection with or arising out of the Agreement, shall be referred to for arbitration who will give written award of his decision to the Parties. Arbitrator will be appointed by ESIC, Hqrs. Office. The decision of the Arbitrator will be final and binding. The provision of Arbitration and Conciliation Act, 1996 shall apply to the arbitration proceedings. Any legal dispute to be settled in Delhi, Jurisdiction only. 6. MISCELLANEOUS: -

a) In emergency medical conditions of the patient, the Hospitals should be prepared

to inform reports over the telephone/email. b) Nothing under this agreement shall be construed as establishing or creating

between the Parties any relationship of Master & Servant or Principle and Agent between the ESIC and Empanelled Centre.

c) The Empanelled Hospital/Centre shall not represent or hold itself out as an agent of the ESIC. The ESIC will not be responsible in any way for any negligence or misconduct of the Empanelled Hospital and/or its employees for any accident, injury or damage sustained or suffered by any ESIC beneficiary or any third party

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resulting from or by any operation conducted by and behalf of the hospital or in the course of doing its work or perform their duties under this agreement of otherwise.

d) This agreement can be modified or altered only on written agreement signed by both the parties.

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Annexure ‘A1’ APPLICATION FORMAT FOR EXPRESSION OF INTEREST FOR

EMPANELMENT OF HOSPITAL FOR SUPER SPECIALITY TREATMENT

1. Name of the city, district and state where the Hospital is located

2. Name of the Hospital

3. Address of the Hospital

4. Distance from nearest ESIC Hospital, Rohini/Basaidarapur/Jhilmil/Okhla/Noida/

Sahibabad/ Gurugram/ Manesar/ Faridabad.

5. Tel./Fax/e-mail

Telephone no. Fax e-mail address Name and contact details of Nodal persons of Hospital

1. 2.

Whether empanelled with CGHS/state Govt. Yes/No (if yes, enclose approval along with scope of services& validity period) Whether NABH Accredited Yes/No (if yes, enclose approval along with scope of services& validity period) Whether NABL Accredited Yes/No (if yes, enclose approval along with scope of investigations& validity period) A. Details online payment of the application fee and EMD: -

Transaction No.

Transaction Amount

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Transaction Date

B. Total turnover during last financial year. (Certificate from Chartered Accountant is to be enclosed)

C. ECS Transfer Details Bank Account number of the applicant, name of bank & IFSC of Branch (Cancelled cheque to be attached)

PAN/TAN/GST number of firm/proprietor (Photocopy to be attached)

6. Hospital shall offer all available under super speciality Services which are NABH

accredited Name the NABH accredited Super-Specialities (Enclose the detail of Super Specialties)

I. II.

III. IV.

7. Diagnostic services available I. In house Imaging facilities (Yes/No)

II. In house Diagnostic Lab facilities (Yes/No) III. Super-specialty investigations: - CT Scan, MRI, PET Scan, Echocardiography,

scanning of other body parts, Specialized bio-chemical and immunological investigations (Yes/No)

8. Total no. of beds

9. Categories of beds available with number of total beds in following type of wards (Please specify number of beds)

Casualty/ Emergency ward

ICCU/ICU

Private

Semi private (2-3 bedded)

General ward bed (4-10)

Others (Please specify Super Specialty/ Specialty wise dedicated bed strength)

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ADDITIONAL INFORMATION (to be furnished ONLY Hospitals not empanelled with CGHS/State Govt)

10. Specifications of beds with physical facilities/ amenities

Dimensions of ward

Number of beds in each ward

Length

Breadth

(Seven Square meter floor area per bed required) (IS: 12433-part 2:2001)

11. Furnishing specify as (a), (b), (c) and (d) as per index below Amenities a) Bedside table

b) Wardrobe

c) Telephone

d) Any other

12. Amenities specify as (a), (b), (c) and (d) as per index below Amenities A Air conditioner

B T. V

C Room service

D Any other

13. Nursing Care Total no. of Nurses

Total No. of para-medical staff

Category of Bed/ Nurse Ratio (acceptable Actual bed/nurse standard ratio High dependency unit 1:1

14. Alternate power source Yes/No

15. Bed Occupancy (in %)

General Bed

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Semi-Private Bed

Private Bed

16. Availability of Doctors 1. Number of in-house doctors

2. Number of in-house

specialists/consultants

17. Laboratory facilities available

Pathology

Biochemistry

Microbiology

Any other

17. Imaging facilities available

18. No. of Operation Theaters

19. Whether there is separate OT for Specific cases Yes/No 20. Supportive Services Yes/No

Boilers/sterilizers

Ambulance

Laundry

House Keeping

Canteen

Medical Gas plant

Dietary

Others (please specify)

Blood Bank

Pharmacy

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Physiotherapy

21. Waste disposal system as per statutory requirements

22. Essential information regarding Cardiology and CTVS

Number of coronary angiograms done in last one year (2019-2020)

Number of Angioplasty done in last one year (2019-2020)

Number of open-heart surgeries done in last one year (2019-2020)

Number of CABG done in last year (2019-2020)

Number of other heart surgeries done (not included above)- Name & Numbers (2019-20)

23. Renal Transplantation, Haemodialysis/Urology/Urosurgery Number of Renal Transplantations done during last one year (2019-2020)

Number of years this facility is available

Number of Hemodialysis Units

Number of Hemodialysis (please mention sero-positive and negative separately in last one year (2019-2020)

1) The Hospital should have good dialysis unit neat, clean and hygienic like a minor OT. It should have facility of giving bicarbonate haemodialysis, water purifying unit equipped with reverse osmosis. The unit should be regularly fumigated. It should have facility for providing dialysis to sero-positive cases also. The facility should be available round the clock. The centre should have an immunology lab and blood transfusion facility. The dialysis unit must function under the supervision of a nephrologist (please mention deficiency, if any).

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24. Lithotripsy No. of cases treated by lithotripsy in last one year (2019-2020)

Average number of sitting required per case

Percentage of cases selected for Lithotripsy, which required Conventional surgery due to failure of lithotripsy

25. Liver Transplantation- Technical expert with experience in liver Transplantation

Yes/No

Name & qualifications

Month and year since Liver Transplantation is being carried out

No. of liver transplantation done during the last one year

Success rate of Liver transplant

Facilities of transplant immunology lab

Tissue typing facilities

Yes/No

Blood Bank Yes/No

26. Neurosurgery a. Whether the hospital has aseptic Operation theatre for Yes/No Neuro Surgery b. Whether there is Barrier Nursing for Isolation for patient Yes/No c. Whether, it has required instrumentation for Neuro-surgery Yes/No d. Facility for Gamma Knife Surgery Yes/No e. Facility for Trans-sphenoidal endoscopic Surgery Yes/No f. Facility for Stereotactic surgery Yes/No 27. Gastro- Enterology a. Whether the hospital has aseptic Operation theatre for Yes/No Gastro-Enterology & GI Surgery b. Whether, it has required instruments for Gastro- Yes/No

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Enterology-GI Surgery c. Facilities for Endoscopy Yes/No (if yes, specify details) d. Facilities for endoscopic surgeries Yes/No (if yes, specify details) 28. Oncology a. Whether the hospital has aseptic Operation theatre Yes/No for Oncology-surgery b. Whether, it has required instrumentation for Oncology Surgery Yes/No c. Facilities for Chemotherapy Yes/No d. Facilities for Radio-therapy (specify) Yes/No e. Radio-therapy facility and manpower shall be as per Yes/No guidelines of BARC f. Details of facilities under Radiotherapy

g. No. of patients put on radiotherapy in last one year 2019-2020

29. Endoscopic/Laparoscopic Surgery Criteria for Laparoscopic/Endoscopic Surgery a. Center should have facilities for casualty/ emergency ward, full-fledged ICU, proper

wards, proper number of nurses and paramedical, qualified and sufficient number of Resident doctors/specialists. (Yes/No)

b. The Surgeon should be Post Graduate with sufficient experience and qualification in the specialty concerned.

c. He/she should be able to carry out the surgery with its variations and able to handle its complications.

d. The hospital should carry out at least 250 Laparoscopic surgeries during last year (201-2020). No. of surgeries performed___________.

e. Whether the hospital has at least one complete set of laparoscopic equipment and instruments with accessories and have facilities for open surgery i.e. after conversion from Laparoscopic surgery. (Yes/No)

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30. No. of CT Scans done in last one year 2019-2020

31. No. of MRI Scans Done in last one year 2019-2020

32. No. of PET Scans done in last one year 2019-2020

33. No. of Mammography’s done in last one year 2019-2020

34. Any other additional facility in which Hospital specializes/ any other additional facilities for which hospital is willing to offer for ESI patients.

I undertake that the information given above is correct to the best of my knowledge. If any information is found incorrect, then undersigned is responsible for the same and action may be taken by ESIC as deemed fit. I do agree with the terms and conditions mentioned in the EOI document.

Signature of the Applicant Name, Date & Stamp

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Annexure ‘A2’

APPLICATION FORMAT FOR EXPRESSION OF INTEREST FOR EMPANELMENT OF HEALTH CARE ORGANISATIONS (HCO)

(Exclusive Dialysis Centers)

1. Name of the city, district and state where the Hospital is located

2. Name of the Hospital

3. Address of the Hospital

4. Distance from nearest ESIC Hospital, Rohini/Basaidarapur/Jhilmil/Okhla/Noida/

Sahibabad/ Gurugram/ Manesar/ Faridabad.

5. Tel./Fax/e-mail

Telephone no. Fax e-mail address Name and contact details of Nodal persons of Hospital

1. 2.

Whether empanelled with CGHS. Yes/No (if yes, enclose approval along with scope of services& validity period) Whether NABH Accredited Yes/No (if yes, enclose approval along with scope of services& validity period) Whether NABL Accredited Yes/No/NA (if yes, enclose approval along with scope of investigations& validity period)

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A. Details online payment of the application fee and EMD: -

Transaction No.

Transaction Amount Transaction Date

B. Total turnover during last financial year

(Certificate from Chartered Accountant is to be enclosed)

C. ECS Transfer Details Bank Account number of the applicant, name of bank & IFSC of Branch (Cancelled cheque to be attached)

PAN/TAN/GST number of firm/proprietor (Photocopy to be attached)

6. Applied for empanelment: - a) Mention the NABH/NABL accredited facilities/specialties/Super-Specialty

(Enclose the detail of Specialties)

7. Total no. of beds

8. Categories of beds available with number of total beds in following type of wards

(Please specify number of beds) Casualty/ Emergency ward

ICCU/ICU

Private

Semi private (2-3 bedded)

General ward bed (4-10)

Additional Requirement for exclusive dialysis center

Number of Hemodialysis Units

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Number of Hemodialysis done (please mention sero-positive and negative separately in last one year (2019-2020)

The Hospital should have good dialysis unit neat, clean and hygienic like a minor OT. It should have facility of giving bicarbonate haemodialysis, water purifying unit equipped with reverse osmosis. The unit should be regularly fumigated. It should have facility for providing dialysis to sero-positive cases also. The facility should be available round the clock. The dialysis unit must function under the supervision of a nephrologist (please mention deficiency, if any).

9. Any other additional facilities for which the Center is willing to offer for ESI patients.

I undertake that the information given above is correct to the best of my knowledge. If any information is found incorrect, then undersigned is responsible for the same and action may be taken by ESIC as deemed fit. I do agree with the terms and conditions mentioned in the EOI document.


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Annexure ’B’

Certificate of Undertaking

(On a Non-Judicial Stamp paper of Rs. 100/-)

1. It is certified that particulars furnished in the Expression of Interest are correct and the eligibility criteria are satisfied and also fully understand in case any incorrect information/misrepresentation, the EMD/ Performance Security Deposit will be forfeited.

2. The hospital shall provide cashless facilities to all ESI beneficiaries referred through

proper ESIC referral system.

3. In case an ESIC beneficiary (with valid ESIC Card and eligibility) approaches the hospital in dire life threatening emergency condition without proper referral documents and subsequent covering referral is also not received from the competent authority for such direct admission, he/she would be provided treatment on Cash basis at CGHS rates or the rates charged from other patients whichever is lower.

4. That the Hospital rates have been provided against a

facility/Procedure/investigation actually available and performed within the organization.

5. I/We have gone through the annexure “F” detailing SOP of ESIC-SOP for online bill

processing and agree to the same and further undertake that the Hospital has the capability to submit the bills through UTI-ITSL and medical cards in digital format and that all billing will be done in electronic format.

6. That the hospital has neither been de-empanelled/derecognized during past one

year nor been blacklisted by CGHS or any other state or other organizations during past three years.

7. That the hospital will pay damage to the ESIC beneficiary or the attendant or ESIC

Staff who accompanies the patient, if any injury loss of part or death occurs due to gross negligence.

8. No investigation by Central Government/ State Government or any other statutory

investigation agency is pending or contemplated against the hospital.

9. I/We agree to the terms & conditions prescribed in EOI Document.

10. The hospital is fulfilling all special conditions _________ (please mention) that have

been imposed by __________ (please mention the authority) authority in lieu of special land allotment or custom duty exemption.

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11. The hospital agrees to implement EMR (electronic medical record) & EHR (electronic health record) as per the standards approved by Ministry of health & Family Welfare.

12. That if any information is found to be untrue at any time before and during the

period of empanelment, the hospital would be liable for de-recognition by ESIC. The hospital organization will be liable to pay compensation for any financial loss caused to ESIC or Physical/mental injuries to its beneficiaries.

13. All the papers of EOI document and all the papers submitted along with EOI

document have been signed and stamped on each page by the authorized person.

14. The hospital has the requisite approval of AERB/NOTTA registration/PNDT Act registration/Fire safety (as applicable).

15. The hospital undertakes to abide by norms of Pollution Control Authority for Bio-

Medical Waste Disposal.

16. The Hospital shall at all times, indemnify and keep indemnified ESIC against all actions, suits, claims and demands brought or made against in respect of anything done or purported to be done by the Hospital in execution of or in connection with the services under the Agreement and against any loss or damage to ESIC in consequence to any Action or suit being brought against the ESIC in the course of the execution of the Agreement.


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Annexure ‘C’

Documents to be submitted along with EOI

Scanned File No.1 containing: 1) EOI Document duly signed, stamped & scanned to be uploaded.

Scanned File No. 2 containing: (the following documents to be bunched & uploaded) 2) Signed stamped and scanned copy of transaction report of Application fees & EMD deposited through RTGS to be uploaded. 3) Application Form as per Annexure ‘A1/A2’ whichever is applicable dully filled, signed, stamped & scanned to be uploaded. 4) Certificate of undertaking as per Annexure ‘B’ duly certified, signed & stamped to be uploaded.

Scanned File No. 3 containing: (the following documents to be bunched & uploaded) 5) Signed stamped and scanned Copy of partnership deed / memorandum / articles of

association (as applicable). 6) Registration of Hospital with State Govt./NCT. 7) Signed stamped and scanned Copy of Authority Letter in favor of person applying on

behalf of Hospital on the official letter head of the Hospital. 8) Signed stamped and scanned Copy of cancelled cheque with mention of Valid Account

Number, IFSC code. 9) Signed stamped and scanned Copy of PAN/GST number of the Hospital. 10) Signed stamped and scanned Fire clearance Certificate 11) Signed stamped and scanned Copy of agreement with Waste Management agency.

Scanned File No. 4containing: (the following documents to be bunched & uploaded) 12) Copy of valid accreditation by NABH/NABL as applicable along with scope of services &

validity period. 13) Signed stamped and scanned Copy of empanelment with CGHS/ State Govt mentioning

the scope of services with validity period. 14) Complete signed and stamped copy of all diagnostic facilities/ laboratory investigations

(NABH/NABL accredited) available in-house along with rate-list of facilities/investigations not available in CGHS rate-list as per annexure “D’ duly signed & stamped to be uploaded.

15) Signed, stamped and scanned copy of audited balance sheet, profit and loss account for the financial year (2018-19). For those Hospital who have completed 01 year of existence as on 31/03/2020, may submit provisional balance sheet, profit and loss statement duly certified by director and auditor.

16) Signed stamped and scanned Copy of License for running (If Applicable)-Multiple documents may be joined and uploaded as single file.

1). Blood Bank 2). Imaging Centre 3). Organ & Tissue transplantation center. 4). Radiotherapy Centre. 5). Any other (Please mention)

17) Signed stamped and scanned Copy of Certificate issue by AERB / BARC/PNDT etc. (which ever applicable)

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Note: Check list as per Annexure ‘C’ to be downloaded as .xls sheet and filled with options Yes/No, Remarks, if any. The same is to be uploaded on in the .xls format itself.

Signature of the Applicant

Name, Date & Stamp

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Annexure ‘D’ Actual Rate list of hospital for facility/investigation not available in CGHS Rate List. Complete list of investigations available in-house which are NABL/NABH accredited

Date: Place

Name & Signature of proprietor/authorized person

with office seal/rubber stamp)

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Annexure “E”

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Annexure-F

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PhotographOf Patientduly attestedby hospitalauthority

(PI)

Letterhead of Referring ESI Hospital (P-I)

Referral Form (Permission letter)

Referral No : Insurance No/Staff Card No/Pensioner Card No :

Name of the Patient :

Address/Contact No : Age/Sex :

Identification marks :

IP/Beneficiary/Staff :

Relationship with IP/Staff : F/M/W/S/D/Other

Entitled for Specialty/Super Specialty : Yes/No

Diagnosis/clinical opinion/case :Summary along with relevanttreatment given/ Procedure/investigationdone in ESIC hospital

Treatment/procedure/SST investigation for :which patient is being referred(mention specific diagnosis for referral)

I voluntarily choose _________________Tie-up Hospital for treatment of self or my _____________

Sign/Thumb Impression of IP/Beneficiary/Staff

18eferred to ________________________________________Hospital/Diagnostic Centre for___________

19ign & Stamp of Authorized Signatory**

** In case of emergency, signature of referring doctor & Casualty Medical Officer. Record tobe maintained in the register. New form duly filled will be sent after signature of thecompetent authority on the next working day.

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Mandatory Instructions for Tie-up Hospital

1 Referral hospital is instructed to perform only the procedure/treatment for which the patient has

been referred.

2 In case of additional procedure/treatment/investigation is essentially required in order to treat the

patient for which he/she has been referred to, the permission for the same is essentially required

from the referring hospital either through e-mail, fax or telephonically (to be confirmed in writing

at the earliest).

3 The referred hospital has to raise the bill as per the agreement on the standard proforma along

with supporting documents within 15 days of discharge of the patient giving account number and

RTGS number etc.

4Food supplement will not to be prescribed/reimbursed.

5Only Generic medicine to be used wherever possible.

6Only those medicine to be used which are FDA/ IP/ BP or USP approved.

Checklist of documents to be sent by referring ESIC/ESIS hospital to tie-up hospital

1Duly filled & signed referral proforma.2Copy of Insurance Card/Photo I card of IP.3Referral recommendation of the specialist/concerned medical officer.4Attested copy of entitlement evidence of Specialty/super specialty treatment.5Reports of investigations and treatment already done.6One additional Photograph of the patient.

Signature of Competent Authority**

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PhotographOf the Patientverified by tie-up hospitalauthority

(PII-PVI)

To be used by Tie-up hospital (for raising the bill) (P-II)

Letterhead of Hospital with Address & Email/Fax/Telefax number

(NABH accredited/ Superspecialty Hospital)(Attach documentary proof)

Individual Case Format

Name of the Patient : Referral S.No.(Routine) /Emergency/ through SMC :

Age/Sex :

Address :

Contact No :

Insurance Number/Staff Card No/Pensioner :3ard no.4ate of referral :Date of AdmissionDate of Discharge

Diagnosis :

Condition of the patient at discharge :

(For Package Rates)Treatment/Procedure done/performed :

I. Existing in the package rate list’s

CGHS/other Code no/nos for chargable procedures :

S.No. ChargeableProcedure

CGHSCode nowith pageno (1)

Other ifnot on (1)prescribedcode nowith pageno

Rate Amt.Claimed

AmountAdmitted

Remarks

Charges of Implant/device used ……………….

Amount Claimed……………….. Amount Admitted Remarks

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II. (Non-package Rates) For procedures done (not existing in the list of packages rates)

S.No. Chargeable Procedure Amt. Claimed AmountAdmitted

Remarks

III. Additional Procedure Done with rationale and documented permission

S.No. ChargeableProcedure

CGHSCode nowith pageno (1)

Other ifnot on (1)prescribedcode nowith pageno

Rate Amt.Claimed

AmountAdmitted

Remarks

Total Amount Claimed (I+II+III) Rs. ………………..

Total Amount Admitted (I+II+III) Rs. …………………

18emarks

19ign/Thumb impression of patient Sign & Stamp ofAuthorized Signatory

(for Official use of ESIC)

Total Amt payable:Date of payment :

Signature of Dealing Assistant Signature of Superintendent

Signature of Competent Authority (MS/SMC/SSMC)

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To be used by Tie-up hospital (P-III)Letterhead of Hospital with Address & Email/Fax/Telefax

Consolidated Bill Format

Bill No ………………………………… Date ………………………

Bill details (Summary)

SNo Name ofpatient

Ref.No

Diag./Procedurefor whichreferred

ProcedurePerformed/treatmentgiven

CGHS/otherCode (withpage)No/Nos/N.A

Chargesnot inpackagerateslist

AmountAdmitted

Amountentitled

Remarks

Total Claim.

Certified that the treatment/procedure has been done/performed as per laid down norms and the charges inthe bill has/ have been claimed as per the terms & conditions laid down in the agreement signed with ESIC.

It is also certified that all the implants, devices etc used are charged at lowest available market rates.

Further certified that the treatment/ procedure have been performed on cashless basis. No money has beenreceived /demanded/ charged from the patient/ his/her relative.

The amount may be credited to our account no ______________ RTGS no _______________ andintimate the same through email/fax/hard copy at the address.

Signature of Competent AuthorityChecklist

1Duly filled up consolidated proforma.2Duly filled up Individual Pt Bill .proforma.3Discharge Slip containing treatment summary & detailed treatment record.4Bill(s) of Implant(s) / Stent(s) /device along with Pouch/packet/invoice etc.5Referral proforma in original, Insurance Card/ Photo I card of IP/ Referral recommendation

of medical officer & entitlement certificate. Approval letter from SMC/SSMC in case ofemergency treatment or additional procedure performed.

6. Sign & Stamp of Authorized Signatory.

Certificate: It is certified that the drugs used in the treatment are in the standard pharmacopeiaIP/BP/USP/FDA.

Signature of Competent Authority

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Letterhead of Referring ESI Hospital _(P-IV)

Sanction Memo/Disallowance Memo

Name of Referral Hospital (Tie-up Hospital)

Bill No ……………… Bill Date ……………..

S. No/Bill No Name of thePatient &Reference No.

AmountClaimed

AmountSanctioned/admitted

Reasons(s) forDisallowance

Remarks


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Letterhead of Tie-up Hospital with Address details(P- V) Monthly

Bill Special Investigations for diagnosis centres/referral Hospitals

Bill No ……………… Bill Date ……………..

SNo Name ofthePatient &Insurance/Staff no

Date ofReference

InvestigationPerformed

CGHS/othercodenowithpageno

Chargesnot inpackagerateslist

AmountClaimed

AmountAdmitted(entitled)

RemarksDisallowanceswith reasons

Certified that the procedure/investigations have been done/performed as per laid down norms and thecharges in the bill has/ have been claimed as per the terms & conditions laid down in the agreementsigned with ESIC.

Further certified that the procedure/investigations have been performed on cashless basis. No money hasbeen received /demanded/ charged from the patient / his/her relative.

The amount may be credited to our account no ______________ RTGS no _______________ andintimate the same through email/fax/hard copy at the address.


Checklist

1Investigation Report.2Referral Document in original.3Serialization of individual bills as per the Sr. No. in the bill.


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PATIENT/ATTENDANT SATISFACTION CERTIFICATE (P-VI)

I am satisfied/ not satisfied with the treatment given to me/ my patient and with thebehavior of the hospital staff.

If not satisfied, the reason thereof.

No money has been demanded/ charged from me/my relative during the stay at hospital.

Sign/Thumb impression of patient/AttendantNamePhone No.

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