ECHS – Revised Procedure for Procession of Waiver and Sanctions: Online Claims
Central Organisation ECHS
Adjutant General Branch
Integrated HQ of MoD (Army)
Maude Line
Delhi Cantt-110010
BI49778/AG/ECHS/Claim/Policy
30 Aug 17
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(All Regional Centres ECHS)
REVISED PROCEDURE FOR PROCESSING OF WAIVER AND SANCTIONS : ONLlNE CLAIMS
1. Refs:-
(a) Our letter No Bl49779/OutsourcingIAG/ECHS dt 11 Jun 14.
(b) Our letter No BI49770/AGIECHS dt 09 Jun 15.
(c) Our letter No B/49779-Outsourcing/AG/ECHS dt 24 Jul 17.
(d) Our letter No B/49779-Outsourcing/AG/ECHS dt 22 Aug 17.
2. The ‘Online Bill Processing’ was initiated pan India was 01 Apr 15, for
efficient and timely settlement of claims while maintaining transparency between
the ECHS beneficiaries, empanelled hospitals, EPA and Central Org ECHS.
efficient and timely settlement of claims while maintaining transparency between
the ECHS beneficiaries, empanelled hospitals, EPA and Central Org ECHS.
3. The existing timeline for processing of online claims is as under:-
| Ser No |
Details
|
Timeline
|
| Empanelled Hospital Claims | ||
| (a) | Admission Intimation | Within 24 Hrs-from time ADMISSION |
| (b) | Online Submission of Claim | Within 04 Days from Date of Discharge |
| (c) | Submission of Hard Copies of Claim | Within 30 Days from Date of Discharge |
| (d) | Query & Need more Info Reply | Within 30 Days of Query/NMI Date |
| Individual Reimbursement Claims | ||
| (e) | Admission Intimation (EIR) | Within 48 hrs from time of admission |
| Submission of Hard Copy | Within 30 Days from Date of Discharge | |
4. However of late, it has been observed that empanelled hospitals/ECHS
beneficiaries are not adhering to the stipulated timelines and also not
responding to the NMI queries raised by BPA within stipulated time frame,
thereby, delaying the final settlement of online claims.
beneficiaries are not adhering to the stipulated timelines and also not
responding to the NMI queries raised by BPA within stipulated time frame,
thereby, delaying the final settlement of online claims.
5. Based on numerous requests from the environment and to streamline online
bill processing, the revised procedure for processing of waivers and
sanctions of online claims has been formulated and attached along as per Appx
attached to this letter. The time limits for various activities have been
revised as per requests from AFVs /Empanelled Hospitals / Regional Centres and
are exclusive of date of discharge in respective claims. However, it is
pertinent to mention that all the stakeholders to strive for speedy processing
of claims and early settlement by avoiding delays, besides ensuring integrity of
financial claims.
bill processing, the revised procedure for processing of waivers and
sanctions of online claims has been formulated and attached along as per Appx
attached to this letter. The time limits for various activities have been
revised as per requests from AFVs /Empanelled Hospitals / Regional Centres and
are exclusive of date of discharge in respective claims. However, it is
pertinent to mention that all the stakeholders to strive for speedy processing
of claims and early settlement by avoiding delays, besides ensuring integrity of
financial claims.
6. Following amdts are incorporated in Para 6 of this HO letter mentioned at
Para 1(d), regarding one time waiver for all NMI:-
Para 1(d), regarding one time waiver for all NMI:-
(a) For. One time delay condonation for late submission of
physical bills and associated documents is also given whenever online bills have
been uploaded.
physical bills and associated documents is also given whenever online bills have
been uploaded.
(b) Read. One time waiver is hereby accorded for all NMI cases i.e, delay in
intimation of admission, delay in online claim (IP&OP) submission,
delay in submission of hard copy & delay in reply of NMI.
intimation of admission, delay in online claim (IP&OP) submission,
delay in submission of hard copy & delay in reply of NMI.
7. You are requested to disseminate the revised procedure for waivers and
sanctions along with timelines to the environment for strict compliance. The
above policy will be implemented with effect from 01 Oct 17,
sanctions along with timelines to the environment for strict compliance. The
above policy will be implemented with effect from 01 Oct 17,
8, This has the approval of the MD ECHS.
Sd/-
(Niranjan Kumar)
Brig Dy MD
For MD ECHS
APPX
(Refer to Central Org ECHS letter No
B/49778/AG/ECHS/Claim/Policy dt 30 Aug 17)
REVISED PROCEDURE FOR PROCESSING OF WAIVERS AND SANCTION
: ONLINE CLAIMS
: ONLINE CLAIMS
| Ser No | Type of Activity | Procedure in Vogue (Timeline) | Revised Procedure wef 01 Oct 17 | Remarks (Including Disposal of old cases) |
|
EMPANELLED HOSPITAL CLAIMS
|
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| 1 | intimation of Admission to BPA | Within 24 Hrs-from time of admission | Within 48 Hrs from time of admission (Revised Timeline) | One time waiver is accorded for all old cases till 30 Sep 17 |
| Upto 30 days – Waiver by Dir RC on justification | ||||
| Beyond 30 days – No (NO) waiver will be accorded | ||||
| 2 | Emergency Referral (ER) in Emergency Cases | Within 24 Hrs from time of admission | Within 48 Hrs from time of admission (Revised Timeline) | One time waiver is accorded for all old cases till 30 Sep 17 |
| Waiver by OIC Polyclinic upto 07 days from the date of hospitalization I date of discharge whichever earlier (valid justification needed) |
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| Upto 30 days – Waiver by Dir RC on justification | ||||
| Beyond 30 days – No (NO) waiver will be accorded | ||||
| 3 | Online Claim (IPIOP) Submission in BPA portal |
Within 04 working days from date of discharge |
Within 07 working days from date of discharge (Revised Timeline) |
One time waiver is |
| Upto 60 days – Waiver by Dir RC on justification | accorded for all old | |||
| Beyond 60 days – No (NO) waiver will be accorded | cases till 30 Sep 17 | |||
| 4 | Submission of Hard Copy of Claim (IP/OP) to Regional Centre |
Within 30 days from date of discharge | Within 60 days from date of discharge (Revised Timeline) |
One time waiver is accorded for all old cases till 30 Sep 17 |
| Wef 61- 90 days – Waiver by Dir RC on justification | ||||
| Beyond 90 days No NO waiver will be accorded | ||||
| 5 | Need More Information (NW) | Within 30 days from date of NMI | The prevailing procedure of granting waiver at various intervals shall be discontinued wef 01 Oct 17 vide letter No B/49779-Outsourcing/AG/ECHS dt 24 Jul 17 as amended vide our letter No B/49779-Outsourcing/AG/ECHS dt 22 Aug 17 and also a comprehensive guidelines for disposal of NMI cases within stipulated time frame has been issued |
After 180 days, claim to be settled based on available documents with deductions (if needed) or rejected depending upon the status of the claim |
| INDIVIDUAL REIMBURSEMENT CLAIMS (NON EMPANELLED HOSPITALS) |
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| 6 | Intimation of Admission/ Emergency Information Report (EIR) to Polyclinic by ECHS beneficiary/ NOK in case of Emergency admission in Non Empanelled Hospitals |
Within 48 Hrs from time of admission | Within 48 Hrs from time of admission | OIC Polyclinic and Dir RC to ensure that no reimbursement claim remains pending in the system for NMI disposal beyond 180 days |
| Waiver by Dir RC, if intimation recd within hospitalization period |
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| If delayed beyond hospitalization period upto 90 days from date of discharge, application to be processed by Dir RC with justification to Central Org ECHS, as per format fwd vide our letter No 13/49770/AG/ECHS dt 21 Nov 16 |
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| 7 | Submission of Hard Copy of claim to Polyclinic |
Within 30 days from date of discharge | Within 90 days from date of discharge (Revised Timeline) |
|
| Wef 91-180 days from date of discharge, waiver to be given by Dir RC |
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| Beyond 180 days from date of discharge, waiver to be given by Central Org ECHS |
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| 8 | Need More information (NMI) | Within 30 days from date of NMI | There is no stage wise time restriction imposed on the individual reimbursement claims and a comprehensive guidelines for processing of Individual Reimbursement Claims has been issued vide letter No B/49779-Outsourcing/AG/ECHS dt 24 Jul 17 GOVT HOSPITALS |
|
| 9 | Treatment in Govt Hospitals | ECHS beneficiary may avail treatment without obtaining referral from polyclinics. However, referral will only be required for the specified treatment such as Organ Treatment Surgery, Knee and Hip Joint Replacement, Cancer Treatment, Neurosurgery and Cardiac Surgery vide Gel, MoD letter No 22D(09)/2013/US(WE)/ D(Res) dt 26 Jul 16 |
Intimation of Admission within 48 Hrs by ECHS beneficiary / NOK to parent / nearest Polyclinic |
|
| Within 90 days from date of discharge – Hard copy of claim by ECHS beneficiary / dependent should be submitted at Polyclinic |
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| Upto 180 days – Waiver by Dir RC on justification for delay in admission intimation and referral both |
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| Beyond 180 days from date of discharge, waiver to be given by Central Org ECHS for delay in admission intimation and referral both |
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MISC CONCURRENCE CASES
|
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| 10 | Misc concurrence required by BPA to process the claims, as follows (a) Discrepancy in overlapping of admission and discharge dates (b) Repeated admission for same ailment within short duration (c) On table procedure/additional procedure done |
No policy exists | Waiver to be given by Central Org ECHS. Cases to be examined in detail by RC and fwd with due justification and recommendation of Dir RC as per format fwd v de our letter No 13/497713/AG/ECHS/ Claim/Policy dt 03 Nov 16 |
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SANCTIONS
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| 11 | Approval on Appx ‘A’ of Cardiologist of Comd 1 Zonal Hospital for:- (a) Unlisted procedures. (b) Cardiac implants (listed 1 unlisted). (c) More than 02 DES and 01 Base Metal Stent (PTCA) |
Approval given by Cardiologist after physical checking of all relevant Documents |
Status quo to be maintained. However, PC/RC may consider feasibility to obtain online approval to save time and subsequently hard copy to be sent by post |
In case of emergency, no approval need to be taken |
| 12 | Organ Transplant (Liver & Lungs) | Approval given by MD ECHS | Status quo to be maintained | |
| 13 | Approval on Appx ‘A’ for Unlisted Procedure/Test/Implants at ECHS Empanelled Hospital |
Approval given by SEMO on revised Appx ‘A’ as per our letter No B1497781 AG/ECHS/PA/Ruling dt 03 Feb 17 |
Status quo to be maintained | |
| 14 | Extended Hospital Admission on Appx ‘A’ | 13-30 days by OIC Polyclinic | Status quo to be maintained | |
| 15 | Extended Hospital Admission on Appx ‘B’ | 31-60 days by Dir RC | Status quo to be maintained | |
| 16 | Extended Hospital Admission on Appx ‘C’ | 61-120 days by MD ECHS | Status quo to be maintained | |
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