Common use of Direct audits Clause in Contracts

Direct audits. In addition to the audit of the audits undertaken by the Insurer referred in Clause 23.3.1.a, the SHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include: (i) Claims audit: For the purpose of claims audit, the SHA shall constitute a Claims Review Committee (CRC) that shall look into 100 percent of the claims rejected or partially settled by the Insurer to assure itself of the legitimacy of the Insurer’s decisions. Claims settlement decisions of the Insurer that are disputed by the concerned EHCP shall be examined in depth by the CRC after such grievance of the EHCP is forwarded by the concerned Grievance Redressal Committee (GRC) to the CRC. CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the SHA shall look into the following aspects (indicative, not exhaustive):  Evidence of rigorous review of claims adjudication.  Comprehensiveness of claims submissions (documentation) by the EHCPs.  Number of type of queries raised by the Insurer during review of claims – appropriateness of queries.  Accuracy of claims settlement.

Direct audits. In addition to the audit of the audits undertaken by the Insurer referred in Clause 23.3.1.a, the SHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include: (i) Claims audit: For the purpose of claims audit, the SHA shall constitute a Claims Review Committee (CRC) that shall look into 100 percent of the claims rejected or partially settled by the Insurer to assure itself of the legitimacy of the Insurer’s decisions. Claims settlement decisions of the Insurer that are disputed by the concerned EHCP shall be examined in depth by the CRC after such grievance of the EHCP is forwarded by the concerned Grievance Redressal Committee (GRC) to the CRC. CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the SHA shall look into the following aspects (indicative, not exhaustive):  • Evidence of rigorous review of claims adjudication.  • Comprehensiveness of claims submissions (documentation) by the EHCPs.  • Number of type of queries raised by the Insurer during review of claims – appropriateness of queries.  • Accuracy of claims settlement.

Direct audits. In addition to the audit of the audits undertaken by the Insurer ISA referred in Clause 23.3.1.a, the SHA NHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include: (i) Claims audit: For the purpose of claims audit, the SHA shall NHA may constitute a Claims Review Committee (CRC) that shall look into 100 percent of the claims rejected recommended for rejection or partially processed by the ISA or partially settled by the Insurer NHA to assure itself of the legitimacy of the InsurerISA’s decisions. Claims settlement decisions of the Insurer ISA that are disputed by the concerned EHCP HCP shall be examined in depth by the CRC after such grievance of the EHCP HCP is forwarded by the concerned Grievance Redressal Committee (GRC) to the CRC. CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCPHCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the SHA NHA shall look into the following aspects (indicative, not exhaustive):  • Evidence of rigorous review of claims adjudication.  • Comprehensiveness of claims submissions (documentation) by the EHCPsHCPs.  • Number of type of queries raised by the Insurer ISA during review of claims – appropriateness of queries.  • Accuracy of claims settlement.

Direct audits. In addition to the audit of the audits undertaken by the Insurer ISA referred in Clause 23.3.1.a23. 3.1. a, the SHA NHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include: (i) Claims audit: For the purpose of claims audit, the SHA shall NHA may constitute a Claims Review Committee (CRC) that shall look into 100 percent of the claims rejected recommended for rejection or partially processed by the ISA or partially settled by the Insurer NHA to assure itself of the legitimacy of the InsurerISA’s decisions. Claims settlement decisions of the Insurer ISA that are disputed by the concerned EHCP HCP shall be examined in depth by the CRC after such grievance of the EHCP HCP is forwarded by the concerned Grievance Redressal Committee (GRC) to the CRC. CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCPHCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the SHA NHA shall look into the following aspects (indicative, not exhaustive):  • Evidence of rigorous review of claims adjudication.  • Comprehensiveness of claims submissions (documentation) by the EHCPsHCPs.  • Number of type of queries raised by the Insurer ISA during review of claims – appropriateness of queries.  • Accuracy of claims settlement.

Direct audits. In addition to the audit of the audits undertaken by the Insurer referred in Clause 23.3.1.a26.3.1(a), the SHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include: (i) Claims audit: For the purpose of claims audit, the SHA shall constitute a Claims Review Committee (CRC) that shall look into 100 percent of the claims rejected or partially settled by the Insurer to assure itself of the legitimacy of the Insurer’s decisions. Claims settlement decisions of the Insurer that are disputed by the concerned EHCP shall be examined in depth by the CRC after such grievance of the EHCP is forwarded by the concerned Grievance Redressal Committee (GRC) to the CRC. CRC shall examine the merits of the case within 30 (thirty) working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCP) as per the provisions specified in the Clause 29 of Grievance Redressal Mechanism. During the claims audit the SHA shall look into the following aspects (indicative, not exhaustive):  Evidence of rigorous review of claims adjudication.  Comprehensiveness of claims submissions (documentation) by the EHCPs.  Number of type of queries raised by the Insurer during review of claims – appropriateness of queries.  Accuracy of claims settlement.