Telefax- 23230484Email -procurement.hqrs@gmail.com

dmc-procurement.hq@esic.in.HEADQUARTERS' OFFICE

EMPLOYEES' STATE INSURANCE CORPORATION( ISO 9001-2000 Certified)

PANCHDEEP BHAWAN, c.I.G ROAD, NEWDELHI.

'\in :U -16130/38/20 l l/Pro-cell/Tie-up arrangement Dated: 15/12/20111b

All Medical Superintendents of ESI & ESIC Hospitals2 All SSMCs/SMCs-' All Regional Ditectors/Jt. Director(I1C).i All Jt. Director(Fin)/Dy. Director(Fin.)/AD.(Fin.)< :\11 Directors. ESI Scheme() Medical Officer In-Charges ,ESI Dispensaries (through Director,ESIS)

Sub: Decisions taken in the meeting held with representatives of Tie-up Hospitals chaired by DirectorGeneral on 25111120 11.

Su/Madam.

Please find enclosed revised formats P-I to P- VI and the decisions taken in the meeting held\\ uh representatives of Tie-up Hospitals chaired by Director General on 25111/201] at ESIC Hqrs.Delhi.

This issues with the approval of Director General.

This is for your information and urgent necessary actionj

Yours faithfully.

\ .lnclosurc. As above (Dr. N.K. Arora)

Dy.Medical CommissionerProcurement -Cell

( 'opy InI) PS/PPS to DG!MC/DMC(Hqrs) For information.2) DhICJI4ig~.DMC(M.E.).DMC(RC).DMqISM) for information.3) Director (F & A),ESIC Hqrs for information .

.-+} Joint Director (System) to upload on ESIC website.."-I Rajbhasha Shakha for Hindi translation. ~ IG-I'~l'

Dy.Medical CommissionerProcurement-Cell

Letterhead of Referring ESI Hospital (P-I)

Referral Form (Permission letter)

k.:lnral l\p Insurance No/Staff Card No/Pensioner Card No

\Jl1re~'./ConlaCI ;'\Jp Age/Sex

Photograph

Of Patient

(optional)

ktenufrcanon mark-, (If any)

IP!lklll' i'ic iary/Staft

Relationship with fP/Staff F/M/S/DIOther

t.uutlcd for Speciality/Super Speciality Yes/No

Dlagl\o~I~/climca I opimon/case-ummary

Relevant Treatment given/ Procedurelluvc-.ugauon done III referring hospital

III vest IgallonffreatmentlProcedure/lnvestigation for

which patient is being referred (mention~,pCClftL" diagnosis for referral)

I voluntarilv choose ________ Hospital for treatment of self or my _

Signffhumb Impression of IPlBeneficiary/Staff

Referred to _______________ Hospital/Diagnostic Centre for

I)all'

Sign & Stamp of Authorized Signatory **

** In case of emergency, signature of referring doctor or Casualty Medical Officer. Record to bemaintained in the register. New form duly filled will be sent after signature of the competentauthority on the next working day.

Mandatory Instructions for Referral Hospital:

Referral hospital is instructed to perform only the procedure/treatment for which the patient has beenreferred toIn case of additional procedure/treatment/investigation is essentially required in order to treat thepatient for which he/she has been referred to, the permission for the same is essentially requiredfrom the referring hospital either through e-mail, fax or telephonically (to be confirmed in writing atthe earl iest )

/Contd ..2/-

/:2:

The referred hospital is requested to raise the bill as per the agreement on the standard proformaalong with supporting documents within 6 days of discharge of the patient giving account numberand RTGS number etc.

Checklist(Re(erring Hospital)1. Duly filled & signed referral proforma.2. Copy of Insurance Card/Photo I card of IP.3. Referral recommendation oj the specialist/concerned medical officer.4. Copy of entitlement evidence of Specialty/super specialty treatment.5. Reports of investigations and treatment already done.6. Photograph. if available

Date:Signature o(the Competent Authority **

(With Stamp)

** In case of emergency, signature of referring doctor or Casualty Medical Officer. Record to bemaintained in the register. New form duly filled will be sent after signature of the competentauthority on the next working day.

• The Photocopy to be sent by Tie-up Hospital to MS/SMC/SSMC while claiming the bill .

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

Letterhead of Hospital with Address & Email/FaxlTelefax number(NABH accredited! Superspeciality Hospital)

(Attach documentary proof)

Date of Submission:

'\alll,' of the Pat ient

Individual Bill Format

insurance Number/Staff Card NolPensionerCard IW.

Date of referral

,Condition of the patient at discharge

(For Package Rates)Treatment/Procedure done/performed

J. Existing in the package rate list

CGHS/olher Code no/nos for chargable proceduresr------r! (I) !

S:\(l(2)

ChargeableProcedure not in

column(3)

Referral S,No.(Routine) IEmergency/ throughSSMC/SMC

Photograph

Of the Patient

verified by

hospital

authority

I (3)

I CGHS code

I no with. page no I

I I.---..----+----.------L-----+----+----+------t-------1I___J -'-I ~ _'__ _'__ _'__ ---'

(4)Other if

i__ .1_

(5) (6) (7) (8)Rate AmI. Amount Remarks

Claimed Admitted (X)with with datedate (X)

Charges of Implant/device used, , " __... , , ... , ....

Amount Claimed _ _.. __ Amount Admitted Remarks

(X) to be filled by ESIC Official(s).

Contd ..2/-

:2:

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

--,-i'~-'T -: s,~o, i (

t---

----------. I (3)(2') (4) (5)"hargeable Procedure I Amt. Claimed with date Amount Admitted Remarks (X)

.._-,. i with date (X)Ii,.L. ,

Ill. Additional Procedure Done with rationale and documented permission"--' _._--..,.

(I) ;

~:--JLl : C'p

(2) , (3) (4) (5) (6) (7) (8)hargeable CGHS Other if not Rate Amt. Amount Remarksrocedure Code no in column (3) Claimed Admitted (X)

with page with date with dateno (X)-

I.----~J. __

Total Amount Claimed(l+II+IIl) Rs ,.,., .

Total Amount Admitted (X) (l+II+III) Rs .

Remarks

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

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

Signffhumb impression of patient with date Sign & Stamp of Authorized Signatory with date(for Official use of ESIC)

Total Amt payable:Date of payment :

SIgnature of Dealing Assistant Signature of Superintendent

Date: Signature of ESIC Competent Authority (MS/SMC/SSMC)

(X) to be filled by ESIC Offlcial(s).

Contd ..3/-

:3:

Checklist(Tie-up Hospitals)1. Discharge Slip containing treatment summary & detailed treatment record.2. Bill! s) of Implant( s) / Stent( s) /device along with Pouch/packet/invoice etc.3. Photocopies of referral proforma, 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.

4. Sign & Stamp of Authorized Signatory.5. Patient/Attendant satisfaction certificate.6. Document in favour of permission taken for additional procedure/treatment or investigation.

• Photocopy of duly filled format to be sent to Tie-up Hospital and original to be kept in record byESIC while informing Tie-up Hospital about approval of claim.

To be used by Tie-up hospital (P-III)

Letterhead of Hospital with Address & EmaillFaxlTelefax

Consolidated Bill Format

Bill No . Date of Submission .

Bill Details (Summary)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)S.No Name Ref. DiagJProced Procedure CGHS/other Other Amount Amount Remarks

of No ure for which Performed! Code (with if not claimed entitled (X)patient referred treatment page) in with with

given NolNoslN.A CGHS date (X) date (X)rateslist

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.

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 and intimatethe same through emaillfaxlhard copy at the address.

Date: Signature of the CompetentAuthority of Tie-up Hospital.

Checklist

1. Duly filled up consolidated proforma.2. Duly filled up Individual Pt Bill .proforma.

Certificate: It is certified that the drugs used in the treatment are in the standard pharmacopeiaIP/BP/USP.It is certified that total amount of Rs has been credited to your account no.______ "RTGS no on _

Date:Signature of the Competent Authority.

(X) to be filled by ESIC Official(s).

The Photocopy to be sent to Tie-up Hospital by MS/SMC/SSMC.

Letterhead of Referring ESI Hospital (P-IV)

Sanction MemolDisallowance Memo

Name of Referral Hospital (Tie-up Hospital)

Bill No ...........•...... Date of Submission .

(1) (2) (3) (4) (5) (6)S.NolBill No Name of the Amount Amount Reasons(s) for Remarks

Patient & Claimed with Sanctioned! Disallowance (X)Reference No. date admitted with date eX)

(X)

Date:

Signature of Competent AuthorityWith Stamp

(X) to be filled by ESIC Official(s).

Photocopy of duly filledformat to be retained by MS/SSMC/SMC and original to be sent to Tie-upHospital while informing Tie-up Hospital about approval of claim.

Letterhead of Tie-up HospitallDiagnostic Centre with Address details(P- V)

Monthly Bill of Special Investigations to be used by diagnostic centres/referral Hospitals

Bill No . Date of Submission .....•........

I (2) (3) (4) (5) (6) (7) (8) (9): (I) Name of Date of Investigation CGHS/ Charges Amount Amount RemarksI SNo the Reference Performed other not in Claimed Admitted DisallowancesI Patient & code package with date (entitled) with reasonsI

I Insurance no with rates with date (X)I /Staff no page no list in (X)

column(5)

..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 agreement signedwith ESIC.

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

The amount may be credited to our account no RTGS no and intimatethe same through emaillfaxlhard copy at the address.

Date: Signature of the CompetentAuthority of Tie-up Hospital

ChecklistI. Investigation Report of each individuallPt.2. Copy of Referral Document of each individuallPt.l. Serialization of individual bills as per the Sr. No. in the bill.

It is certified that total amount of Rs has been credited to your account no., RTGS no on _

Signature of Account department with stamp.

Date:Signature of Competent AuthorityReferral Hospital.

(X) to be filled by ESIC Official(s).

Photocopy of duly filled format to be sent to Tie-up Hospital and original to be kept in record by ESICwhile informing Tie-up Hospital about approval of claim

PATIENT/ATTENDANT SATISFACTION CERTIFICATE (P-VI)

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

2. If not satisfied, the reason(s) thereof.

3. It is stated that no money has been demanded! charged from me/my relative during thestay at hospital.

Authorized Signatory(Tie-up HospitallDiagnostic Centre)with Stamp and Date & time

SignfThumb impression of patient/AttendantWith Date & TimeName of the Patient/attendantName ofIPInsurance No/Staff noDate of AdmissionDate of Discharge

• The Photocopy to be sent by Tie-up Hospital to MS/SMC/SSMC while claiming the bill.

DECISIONS TAKEN IN THE MEETING HELD WITH REPRESENTATIVESOF TIE-UP HOSPITALS CHAIRED BY DIRECTOR GENERAL ON 25.11.2011

Or. N.K. Arora welcomed all the delegates and gave a presentation on the

objectives of the meeting as well as the details of the previous meeting held on 28.04.11.

The decisions taken by the Committee constituted by Director General in the previous

meeting were presented including the formats prepared to be used by referring

hospitals, tie up hospital and diagnostic centres for referral and claiming the payments

thereof. The matter of new ESIC treatment package rates finalized by the committee was

also put forth.

Sh. Arvind Kumar, Jt. Director, Medical Vigilance Wing gave a presentation on

review of referral system in ESIC. He gave the brief introduction about different

circulars issued from ESIC headquarters from time to time regarding super specialty

treatment to IPs & beneficiaries. He also stressed on the need of scrutiny of medical

records / identification of ESI patients (to check that only genuine IPs/ beneficiaries are

being treated) admitted at tie up hospitals. He also stressed on the details to be sent by

tie-up hospital regarding patients admitted in tie up hospitals in the prescribed format

already circulated to tie up hospitals. The representatives stated that they do not have

much information about the particulars of the employer which is a part of the format. It

was decided that whatever information they can gather should be mentioned in the

prescribed proforma and be sent on daily basis.

Director General stated that Medical Vigilance Wing has been created at Hqrs. Officelevel to monitor the functioning of the tie up hospital regarding the treatment being

given to ESI beneficiaries. He stated that genuine ESI patients should be treated. The

bills should be submitted correctly and verified correctly. He stressed on the need of

occasional visits by the authorized ESI representatives to tie up hospitals to check the

genuineness of the patients and treatment being given to them.

DECISIONS TAKEN IN THE MEETING ARE:

1) The Director General instructed the Committee already constituted (in the

previous meeting) should meet regularly and solve the issues raised by tie up

hospitals from time to time. He requested the tie up hospitals to send their

apprehensions and eo-opt with the members of the committee (already

constituted). He stated that, if there is frequent defaulter among the

Committee members from tie up hospitals, the person can be replaced by

some other one who is interested.

2) The MoU should be modified and the different types of discounts (15%

discount on hospital rates,for the facilities for which the hospital is notempanelled by ESIC, for devices/stents etc, 15% discount on MRP(Maximum

Retail Price) and For drugs 10% discount on the MRP) to be given on the

procedures/ devices / drugs which do not exist under CGHS approved list

should be included in MOU. Regarding the patients admitted in tie-up

hospitals, the empanelled hospitals should levy CGHS or ESIC approved rates

for which the tie-up hospitals are not empanelled. If no such rates are

available, then the tie-up hospitals shall offer 15% discount on normal

scheduled rates of the hospital.

3) a) The representatives were also requested to allow ESIC authorized

representatives to screen the records of ESIC patients~t;Jated there.

b) The tie up hospital should send up to date information about ESIpatients admitted in their hospital, on daily basis through mail to

respective Medical Superintendents / SSMCs/ SMCs.

4) a) Tie up hospitals should enclose the sub-bills / particulars of the stent /

devices / drugs etc. while submitting the bills to ESI Corporation

(Medical Superintendents / State Medical Commissioners ). This will

prevent unnecessary delay in clearing the bills.

b) It was also decided that if some discrepancy is found in the bills

submitted by tie up hospitals, the phone call can be made to them by the

paying authority so as to get the bills corrected on the spot. D.G.

stressed on the need of formulation of more treatment package rates to

avoid the tedious procedure of verification of bills. He reiterated on

the payment to tie up hospitals through ECS.

5) a) There was apprehension by the tie up hospitals regarding availability of

the photograph of the patient admitted there. After deliberations, it

was decided that if photograph is not available, some identification

b) It was also decided that the identification marks as mentioned in the

referral form be verified by the treating hospital and the copy be sent

back while claiming the bill for treatment of the patient.

6) Necessary changes in the formats P.! - P.VI were decided and incorporated.

7) It was also decided that the M.S./ State Medical Commissioners will have

meetings with the tie up hospitals every two months in their respective region.

8) There was some apprehensions regarding the ESIC package rates. The

representatives of tie up hospitals were requested to eo-opt with Committee

Members which was constituted by D.G. in the previous meet~·ng..tJ)C ~ fk ,..,.,..,."

9) Director General asked the Committee to "t;t OQt" ie _up \ospital

empanelment policy.

(List of participants given in annexure-A)

The meeting ended with a vote of thanks to Chair and all the delegates. 1/

Annexure-A

List of participants who attended the meeting held with representatives of tie-up hospitals

chaired by Director General on 25/11/2011:-

ESICSr.No.

DesignationTie-Up Hospitals

Director 1. Dharamshila Hospital~ +- ~G__e_ne_r_a_' ~ __ +-&__Re_s_e_a_rc_h__c_en_t_r_e__ ~ +- ~I 2. Dr. Surinder Medical 2. Dharamshila Hospital Mrs. Indu Agarwal Finance;

Kumar Commissioner & Research Centre

Name

1. I Dr. C.S. Kedar

Sr. Name of theNo. Organization

Dr. Naresh DMC 3. Delhi Heart HospitalI Kumar (Procurement

Cell)

Name of theRepresentativeDr. Raja Dutta

Dr. B.L. Jain

Designation

MS

Director

Dr. Rajpal DMC(MedicalVigilance)

Dr. Kayam Singh DMC (RC Cell)

8.

Dr. NaveenSaxena

OSD(Hqrs.)

/4.I

4. Rockland Hospital Dr. R.C.Sharma

Sonia Verma

V.P. (Operation)

Marketing Head

Dr. Vivek Handa DMC (ME)

5. Umkal Hospital &Metro Heart Institute

Rajni Bala Marketing

17.i

Or. AbhimanyuPanda

OMC(Sytem)

6. Fortis Jessa RamHospital

Renu Rai Billing Head

Sh. Arvind Kumar JD(MedicalVigilance)

7. Fortis Jessa RamHospital

Gulshan Arora GM (CorporateSales)

9.

8. FortisHealthcare(lndia)Limited

Prashant Bisht OM (CorporateSales)

9. FortisHeatthcaretlndia)Limited

10. Dr. Nilanjan OSD (Vigilance) 10. Pushpanjali Crosslayhazarika Hospital

Dr. Aman Khera ConsultancyBusiness Dev.

I 11. Dr. H.K. Satia Directorate 11. Pushpanjali Crosslay; I (Medical)Delhi Hospital

Dr. T.S. Jain Medical Director

Manager(Mrktg)Medical Admn

I 20. Max Hospital, Saket Mr. Arun Pandey Asstt. Manager

I 19. Indraprastha Apollo, I hospital

Surender Singh Asstt. Manager

~ ~ ~2~1~.-+~M~a~x~H~o~s~p_it~a~I,~S~a_k~et__ 1-M__r._S_a~c~h-in-B~h-a~t-ia--r-A-ss-t~t.-M~an~a~g~e-r~1 I 22. Delhi heart & lung Dr.Neelam Seth Medical DirectorI, I Institute: I 23. Delhi heart & lung

Institute~-4-'--------~------~--~~=---~--~~--~--~~--~~, , 24. S.L.Jain hospital Sh. Dhananjaya Manager MrktgI I, 1 Punj~-----+------------~r------------r~-+~~--~~------~~~~~------~~~~----~! 25. Sunderlal Jain Sh. Manish GM-MrktgI

Hospital Agrawal~'~-----------+----------~~--~----~~~~~~~----r---------~, 26. Metro Hospitals & Sh. P.K.Sharma AVP- CorporateI Hearet Institute Affairs1-r-1--·'---------+-----------1f-2-7-.-+--W-o-c~k:-ha-r~d~t-H-O-sP~i-ta-:-ls-I-S::-:h-.~V-:-.p::-.-:-K-:-a-m-a-t:-h-1-C::-:-h-:-ie~f:-O::-p-e-r-at-:-in-:g---i

Officeri I .----------+-------+----+--~-----_+--~~--_t_-----___{! 1 28. Wockhardt Hospitals Sh. Ritesh Sr. ManagerI I Chhaweharia

Dr. S.H. Rizvi GM- Mrktg

I 29. KIMS Dr. B.Bhaskar Rao MD & CEOf--_+--------~r_------_+--+_-----------r~--~----~------~I 30. Medanta the Sh. Sandeep DGMi medicity Dawar\1' 31. Medanta the Sh. Kailash Arora

medicityGen. Manager

I 32. Asian Institute ofMedical Science

AGM

~I 33. Asian Institute ofMedical Science

Sh. S.K.Jha

Sh. Ankur Arora Manager

34. NMC Imaging &diagnostic CentreL--_+- ~----------~---+--~-----------~--------------+_---------~

I 35. NMC Imaging &iI diagnostic Centre

Sh. Raj Kumar

Sh. DevenderSingh Yadav

Manager

Sr. Manager(Admn)

I 36. NMC Imaging &I diagnostic Centre

Sr. ManagerSh. Hari RamSharma

\

37. Global Diagnostics DirectorSh. VishalMankotia

I 38. Prakash Hospital,! Noida~--------------r-----------~--~----------------~--------------+_----------~I I 39. Banarsidas: I Chandiwala Instt of! I Medical Sciences

r:I'-=r-----------~----------_r-40--. +-F_o_rt_is__H_O_sp_i_ta_I,~rS_:h-.-A~n-U~ra~g------_+-H-e-a_d_s_a_le_S_&__ ~_ Faridabad Kashyap Mrkt41. Fortis Hospital, Sh. Ashish Tangri Asstt Manager

~ Faridabad: 1'----------+-----------+-4-2-. -+-S-u-n-d-:-e-r-:-Ia-I-Ja-i-n------+-S-h-. D--in-e-s-h-K-r.-----t-s-r-.-M-a-n-a-g-er-----1

_ ..__ I'-I__ . -----' ~ __ __'___H_O_S_PI_·ta_I __L_K_h_a_n_d_e_lw_a_I'--M_r_kt_g --'

Sh. Pramod Rawat

Dr. YogenderTomar

Manager

DMS

43. Sri Balaji Action Med.Instt.

BDD

45.

Sh.SudhakarSharma

44. Action CancelHospital + Sri 8alajiAction Medical

Ms. Jasleen Kaur GM

Sri Balaji Action Med.Instt.

AMSDr. Archana Atreja

46. Paras Healthcare Pvt.I ~

Dr. ParveenKumar

MS

AGMi 47. Paras Healthcare Pvt.I Ltd

Sh.JitenderKumar

AOI I 48. National HeartI : Institute~--ti--------~---------r--~----------+----------r----~~, 49. National Heart Ms. Sushima Mktg headI i Institute Gopal

Sh. S.K.Shally

I I I 50. Mahajan Imaging Sh.TSNegi: I +- -+-_+-C_en_t_re --t t-- -JI r 51. Mahajan Imaging Pvt Sh. Anil Karkhanis GM

Ltd

liaison Manager

ConsultantRadiologist

I 53. Chaudhary Eye

~

--------~------------~--~c-e-n-t-re~,-D-a-ry~a~g~a~n~j--~------------ __ +_----------~54. Maharaja Agarsen Dr. Bharti Saxena AMS

Hospital: 55. Maharaja Agarsen Ms. Poonam Ittan Head Mrktg

l. +-- ~----------_t----f--H-O-sp-i-ta-I----------+_------------_t-~-Be.:....uv_s~_~o~ep.:....s~ e_nt...!..)~I 56. Clinical Daignostic Sh.Akshay Kumar Sr. ManagerI Centre (Admn & Mrktg)

! 52. Dr. Anand's tmagingI & NeurologicalI research Centre

Dr. Geeta Anand

Mr. Abhishek Sr. Exec.Mrktg

~

I _+-- ~----------_t-5-7-.~-D-e-lh-i-l-ns-t-it-u-te~o~f~_+-S_h~.~B_ra_je_S_h_K_r_.__ _t-M--a-n-ag-e-r----~Functionallmaging Singh58. Delhi Institute of Sh. Mahipal singh PRO

, Functionallmaging RawatI--- 59. Kalra Hospital SRCNC Dr. Abhinav SainL__'-_~_----L--_-----'---'--~_-'---_~ __MS