Common use of Monitoring and verification Clause in Contracts

Monitoring and verification. The SHA shall, either directly or through the ISA or any of its authorised representatives, shall have the right to conduct monitoring visits and random audits of any or all cases of hospitalisation and any or all claims submitted by the EHCP. Monitoring of EHCPs shall include but not be limited to: Overall performance and conduct of the EHCP Beneficiary registration process Pre-authorisation and claims submission process EHCP facility and infrastructure. The scope of medical audit of services provided by the EHCP shall focus on ensuring comprehensiveness of medical records and shall include but not be limited to: Completeness of the medical records file Evidence of patient history and current illness Operation report (if surgery is done) Patient progress notes from admission to discharge Pathology and radiology reports. If at any point in time the SHA issues Standard Treatment Guidelines for all or some of the medical/ surgical procedures, assessing compliance to Standard Treatment Guidelines shall be within the scope of the medical audit. The SHA/ISA shall conduct the medical audit through on-site visits to the EHCP facility for inspection of records, discussions with the nursing and medical staff. The SHA/ISA shall conduct hospital audit of the EHCP that will focus on compliance to minimum empanelment criteria including but not limited to facilities, infrastructure, human resources, medical record keeping system and EHCP’s obligations like operational help desk, appropriate signage of the Scheme prominently displayed. The EHCP shall be obliged to provide unconditional support to the ISA or any of its authorised representatives in all their monitoring activities which shall include but not be limited to providing access to the hospital facility, patients and record for planned and unplanned supervision visits, providing copies of all medical records of AB-PMJAY beneficiaries as required for purposes of audit or otherwise and any other cooperation and support that may be required under the provisions of this Agreement. Section12: Relationship of the Parties Nothing contained herein shall be deemed to create between the Parties any partnership, joint venture or relationship of principal and agent or master and servant or employer and employee or any affiliate or subsidiaries thereof. Each of the Parties hereto agrees not to hold itself or allow its directors employees/agents/representatives to hold out to be a principal or an agent, employee or any subsidiary or affiliate of the other.

Monitoring and verification. The SHA shall, either directly or through the Insurer / ISA / TPA or any of its authorised representatives, shall have the right to conduct monitoring visits and random audits of any or all cases of hospitalisation and any or all claims submitted by the EHCP. Monitoring of EHCPs shall include but not be limited to: Overall performance and conduct of the EHCP Beneficiary registration process Pre-authorisation and claims submission process EHCP facility and infrastructure. The scope of medical audit of services provided by the EHCP shall focus on ensuring comprehensiveness of medical records and shall include but not be limited to: Completeness of the medical records file Evidence of patient history and current illness Operation report (if surgery is done) Patient progress notes from admission to discharge Pathology and radiology reports. If at any point in time the SHA issues Standard Treatment Guidelines for all or some of the medical/ surgical procedures, assessing compliance to Standard Treatment Guidelines shall be within the scope of the medical audit. The SHA/ISA Insurer/TPA shall conduct the medical audit through on-site visits to the EHCP facility for inspection of records, discussions with the nursing and medical staff. The SHA/ISA Insurer/TPA shall conduct hospital audit of the EHCP that will focus on compliance to minimum empanelment criteria including but not limited to facilities, infrastructure, human resources, medical record keeping system and EHCP’s obligations like operational help desk, appropriate signage of the Scheme prominently displayed. The EHCP shall be obliged to provide unconditional support to the Insurer / ISA / TPA or any of its authorised representatives in all their monitoring activities which shall include but not be limited to providing access to the hospital facility, patients and record for planned and unplanned supervision visits, providing copies of all medical records of ABAB PM-PMJAY XXX beneficiaries as required for purposes of audit or otherwise and any other cooperation and support that may be required under the provisions of this Agreement. Section12: Relationship of the Parties Nothing contained herein shall be deemed to create between the Parties any partnership, joint venture or relationship of principal and agent or master and servant or employer and employee or any affiliate or subsidiaries thereof. Each of the Parties hereto agrees not to hold itself or allow its directors employees/agents/representatives to hold out to be a principal or an agent, employee or any subsidiary or affiliate of the other.

Monitoring and verification. 1. The SHA shall, either directly or through the Insurer / ISA / TPA/ISA or any of its authorised representatives, shall have the right to conduct monitoring visits and random audits of any or all cases of hospitalisation and any or all claims submitted by the EHCP. 2. Monitoring of EHCPs shall include but not be limited to: : i. Overall performance and conduct of the EHCP EHCP ii. Beneficiary registration process process iii. Pre-authorisation and claims submission process process iv. EHCP facility and infrastructure. 3. The scope of medical audit of services provided by the EHCP shall focus on ensuring comprehensiveness of medical records and shall include but not be limited to: : i. Completeness of the medical records file file ii. Evidence of patient history and current illness illness iii. Operation report (if surgery is done) ) iv. Patient progress notes from admission to discharge discharge v. Pathology and radiology reports. 4. If at any point in time the SHA issues Standard Treatment Guidelines for all or some of the medical/ surgical procedures, assessing compliance to Standard Treatment Guidelines shall be within the scope of the medical audit. 5. The SHA/TPA/ISA shall conduct the medical audit through on-site visits to the EHCP facility for inspection of records, discussions with the nursing and medical staff. 6. The SHA/TPA/ISA shall conduct hospital audit of the EHCP that will focus on compliance to minimum empanelment criteria including but not limited to facilities, infrastructure, human resources, medical record keeping system and EHCP’s obligations like operational help desk, appropriate signage of the Scheme prominently displayed. 7. The EHCP shall be obliged to provide unconditional support to the Insurer / ISA / TPA or any of its authorised representatives in all their monitoring activities which shall include but not be limited to providing access to the hospital facility, patients and record for planned and unplanned supervision visits, providing copies of all medical records of ABAB PM-PMJAY XXX beneficiaries as required for purposes of audit or otherwise and any other cooperation and support that may be required under the provisions of this Agreement. Section12: Relationship of the Parties Nothing contained herein shall be deemed to create between the Parties any partnership, joint venture or relationship of principal and agent or master and servant or employer and employee or any affiliate or subsidiaries thereof. Each of the Parties hereto agrees not to hold itself or allow its directors employees/agents/representatives to hold out to be a principal or an agent, employee or any subsidiary or affiliate of the other.

Monitoring and verification. The SHA shall, either directly or through the Insurer / ISA / TPA/ISA or any of its authorised representatives, shall have the right to conduct monitoring visits and random audits of any or all cases of hospitalisation and any or all claims submitted by the EHCP. Monitoring of EHCPs shall include but not be limited to: Overall performance and conduct of the EHCP Beneficiary registration process Pre-authorisation and claims submission process EHCP facility and infrastructure. The scope of medical audit of services provided by the EHCP shall focus on ensuring comprehensiveness of medical records and shall include but not be limited to: Completeness of the medical records file Evidence of patient history and current illness Operation report (if surgery is done) Patient progress notes from admission to discharge Pathology and radiology reports. If at any point in time the SHA issues Standard Treatment Guidelines for all or some of the medical/ surgical procedures, assessing compliance to Standard Treatment Guidelines shall be within the scope of the medical audit. The SHA/TPA/ISA shall conduct the medical audit through on-site visits to the EHCP facility for inspection of records, discussions with the nursing and medical staff. The SHA/TPA/ISA shall conduct hospital audit of the EHCP that will focus on compliance to minimum empanelment criteria including but not limited to facilities, infrastructure, human resources, medical record keeping system and EHCP’s obligations like operational help desk, appropriate signage of the Scheme prominently displayed. The EHCP shall be obliged to provide unconditional support to the Insurer / ISA / TPA or any of its authorised representatives in all their monitoring activities which shall include but not be limited to providing access to the hospital facility, patients and record for planned and unplanned supervision visits, providing copies of all medical records of ABAB PM-PMJAY XXX beneficiaries as required for purposes of audit or otherwise and any other cooperation and support that may be required under the provisions of this Agreement. Section12: Relationship of the Parties Nothing contained herein shall be deemed to create between the Parties any partnership, joint venture or relationship of principal and agent or master and servant or employer and employee or any affiliate or subsidiaries thereof. Each of the Parties hereto agrees not to hold itself or allow its directors employees/agents/representatives to hold out to be a principal or an agent, employee or any subsidiary or affiliate of the other.